Benefit Design and Contract Review

A complete analysis is conducted of all current programs in light of management’s objectives and includes identification of potential problem areas. Current and potential contracts are thoroughly reviewed for completeness and accuracy. We review Plan Documents and SPDs for accuracy prior to distribution and ensure that they are legally compliant. We also conduct thorough compliance reviews on:

  • Form 5500 and related documents;
  • Coverage continuation arrangements, COBRA and state specific requirements;
  • Medicare Part D notification and filing requirements, Child Health Insurance Plan (CHIP) notice requirements;
  • Identifying action steps that need to be taken to align benefit plan design with PPACA;
  • Administrative systems to assure compliance with future automatic enrollment and W-2 tax reporting standards;
  • Other federal and state employee benefit-related regulations.


Recommendations on all areas of cost effectiveness, benefits, and contract provisions are communicated to our clients for consideration. These recommendations are based on thorough evaluations of the factors that impact our clients’ current and future benefit spend, including the client’s business, culture, and employee population; carrier and vendor charges; employee contributions; claims and utilization; plan design and options; funding methods; recruitment and retention (competitiveness of the program); health and wellness; regulations and legal exposures; and program administration. Through a consultative and advisory role, we gather, interpret, and present all relevant data so that our clients understand all available options and can make informed decisions. Once these decisions are made, our firm takes full responsibility for interfacing with carriers, implementing the client’s programs, and analyzing results as the basis for preparing for the following year’s renewal.

Uniform Specifications and Bid Analysis

Tikia Consulting Group prepares uniform specifications to be released to a number of insurance carriers and/or third party administrators with customized requests that fit our clients’ objectives. An underwriting analysis and a report analyzing the rates, contract provisions, technological and service capabilities, and pros and cons are prepared to assist our client in selecting an insurance carrier or third party administrator.

Transition to a New Carrier

When a new carrier is selected or changed, we assist by:

  1. Coordinating the transfer of information, such as deductible and coinsurance reports, lifetime maximum reports, eligibility reports, among others, from the prior claims payer to the new TPA;
  2. Conducting ongoing conversations with the prior carrier to ensure all documentation is received on any pended, incurred but unreported, and open claims in order for the new TPA to process any pended (or soft-denied) claims;
  3. Ensuring that the new TPA verifies plan design, pre-existing condition limitations, any large catastrophic claims, compliance with HIPAA and USERRA guidelines, current COBRA beneficiaries, extension of benefits provision and claims that hit 50% or more of the specific deductible;
  4. Evaluating the current stop-loss contract in order to ensure a “full takeover,” with no gaps in coverage;
  5. Verifying online eligibility with the new TPA or carrier if desired;
  6. Ensuring that verification of benefits, rollover provisions, waiver of premium provisions and legislative compliance are all reviewed for accuracy on any ancillary products.

Implementation of a New Benefits Program

We assist during the change by:

  1. Verifying the accuracy of contracts purchased on specific and aggregate insurance as well as agreements with the TPA, PPO and Managed Care Services Organizations;
  2. Assisting during the application process, including the disclosure of any employees not actively-at-work or hospital-confined dependents;
  3. Reviewing, altering and customizing creative plan design recommendations for the Summary Plan Description (SPD) and Plan Document;
  4. Preparing all employee communication materials, including Section 125 Premium Conversion Only (POP) forms for employee meetings;
  5. Conducting employee meetings with regard to all products involved including Life, AD&D, STD, LTD, Medical, Dental, Vision, FSA, Section 125, EAP and the Prescription Drug Card;
  6. Reviewing the initial bill for accuracy and ease of understanding, if requested;
  7. Coordinating any plan design changes with both the reinsurer and the TPA or carrier;
  8. Helping employees complete the enrollment process and reviewing forms for accuracy;
  9. Responding to any issues raised by both employees and employers during the enrollment process.

Ongoing Services

We monitor the plan on an ongoing basis by:

  1. Assisting in any claim related problems;
  2. Monitoring turn-around time and claims payment accuracy on an ongoing basis;
  3. Reviewing claims data on a monthly and semi-annual basis to proactively spot any trends developing;
  4. Preparing a six-month underwriting report projecting renewal for budget purposes;
  5. Regularly reviewing claims by employees vs. dependents, in-patient vs. out-patient costs, PPO penetration, provider abuse cases and catastrophic claims;
  6. Making any ongoing plan design recommendations to correct abuses and align with industry norms and client specific utilization;
  7. Monitoring PPO savings and utilization for successful results;
  8. Coordinating and researching requests for Large Case management; tracking high dollar claimants and monitoring specific reimbursements received from reinsurance carriers;
  9. Preparing a monthly experience analysis for the Plan, along with specialized reports, illustrating all costs associated with maintaining the employee benefits program.

Employee Benefits Annual Renewal Process

Each year prior to the renewal date, Tikia Consulting Group will assist by:

  1. Performing our own annual underwriting for comparison purposes to forecast the renewal in order to better negotiate with the carrier;
  2. Checking the market for the competitiveness of the renewal;
  3. Negotiating with a renewal carrier for the absolute best renewal by keeping up with market trends, pooling charges, retention levels, etc;
  4. Recommending plan design changes, if necessary;
  5. Preparing a report on the success/failure of the PPO and DBC Plans and/or any other form of Managed Care;

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