- Accumulators: Are they applied on a calendar year or plan year and if there is a carrier change, does the new carrier allow credit for expenses incurred during the same accumulation year? For example, a plan renews June 30 and has a calendar-year accumulator. Usually, the new plan will allow credit for expenses applied to the deductible in the prior plan during the same calendar year; however, credit is generally not granted toward out-of-pocket cost maximums.
- Deductible cross-application: Do in- and out-of-network deductibles apply separately or are they cross-applied? Some plans apply in-network deductibles toward out-of-network, but not out-of-network to in-network.
- Deductible for family members: In a non-single plan election, is the deductible per person or per family? If the plan has a $1,000 single deductible and a $2,000 family deductible, is the deductible for one family member considered satisfied once that member has met $1,000 in covered expenses or does the full $2,000 family deductible apply before charges for one or more covered persons are reimbursed?
- Run-out provisions: Should you terminate your plan, how will incurred-but-unpaid claims be processed? Is there an additional cost?
- Shared savings: Generally, the TPA wants to share savings for out-of-network claims when less than the billed cost is paid, and it’s important to understand how this works.
- Subrogation and claim recovery costs: Usually the TPA retains a portion of the recovery for third-party liability and may bill costs associated with collecting these payments.
