HOW PARTIAL SELF FUNDING WORKS (PSF)

Phone: 319-352-1623

800-383-1623

Website: advantageadmin.com

Advantage Administrators is the District’s Self-Funded plan administrator They gather all the claims and pay the difference between the Wellmark policy and the District’s Self-Funded policy. If you have questions or concerns regarding a claim, feel free to call Advantage Administrators for assistance

Partial Self-Funding Defined: With a partially self-funded health plan, the employer contracts a health insurance carrier or third-party administrator (TPA) to administer all aspects of the health plan, including claims adjudication, but the employer funds the claims payments.

Who Makes the Payments?

1. Employee visits the Mercy Hospital in Mason City for an MRI of an injured knee (not an office visit).

2 Employee pays CoPay if required If the amount seems excessive, explain to Mercy that your employer partial self funds the Wellmark plan and that you have a lower deductible/out of pocket max They can contact Advantage Administrators at the number above to verify and ask for assistance Typically, Mercy Hospital will not require the down payment at the time of service if they are informed.

3 Mercy Hospital submits the medical claim to Wellmark (electronically)

4. Wellmark reviews plan deductibles and out of pocket maximums and makes payment to Mercy Hospital based upon higher deductible plan.

5 Wellmark issues Explanation of Benefits (EOB) to Employee

6. Wellmark shares employee’s EOB with Advantage Administrators.

7. Advantage Administrators reviews plan deductibles and out-of-pocket maximums and makes payment to Mercy Hospital based upon the partial self-funded (lower deductible) plan and makes additional payment to the provider.

8 Advantage Administrators issues EOB to employee

9. Employee pays the remaining balance to Mercy Hospital. Wellmark Advantage Administrators Employee Pays Pays on behalf of the Pays District Balance Due