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Administrative Services Only (ASO): A Guide to Self-Funded Healthcare Management

Administrative Services Only (ASO): A Guide to Self-Funded Healthcare Management

Administrative Services Only (ASO) is an arrangement in which an employer elects to self-fund their employee benefit plan while outsourcing the plan’s administration to an external service provider. This model is particularly attractive for employers looking to maintain control over the health benefits they offer while ensuring professional management of the plan by specialists adept in handling claims processing, benefits management, and other related administrative tasks.

Key Takeaways

  • ASO plans allow employers to self-fund their employee benefits while outsourcing administration.
  • These plans require employers to shoulder potential risks but provide flexibility in plan design.
  • Employers can manage costs effectively through ASO but must navigate complex legal frameworks.

Understanding ASO

Administrative Services Only (ASO) arrangements are crucial for employers considering self-funded health plans. In this structure, companies take on financial responsibility for employee claims, while outsourcing administrative tasks to a third party.

What Is ASO?

ASO stands for Administrative Services Only, a plan where an employer funds the health benefits for employees but hires an external third-party administrator to handle the administration. These services can include processing claims, providing customer service, and managing networks. Employers choose ASO arrangements to maintain control over the health plan’s reserves, allowing for potential cost savings and benefit customization.

Differences Between ASO and Fully Insured Plans

The primary difference between an ASO plan and a fully insured plan lies in who bears the risk:

  • Self-funded Plan (ASO)

    Employer bears the risk
    : They pay out claims from their funds.
    Administrative services: Provided by a third-party but not the risk of the claims.
    Flexibility: Offers potential cost savings and customized benefits.

  • Fully Insured Plan

    Insurance company bears the risk: They collect premiums and pay claims.
    Fixed premiums: Paid by the employer to the insurance company.
    Less administrative burden: The insurer manages all aspects of the plan.

Transforming from a fully insured plan to an ASO model can lead employers to more direct involvement in the healthcare benefits they offer, instilling a greater sense of responsibility and potential for cost efficiency.

Benefits of ASO

Administrative Services Only plans are a pragmatic solution for employers seeking cost savings and control over their health insurance benefits. They emphasize financial efficacy, benefits customization, and cash flow management.

Financial Advantages

An ASO model is often associated with significant cost savings for employers. Since companies pay for the actual claims and not a premium, they can avoid the risk charges and profit margins that traditional insurers include in their pricing structures. Employers benefit from the flexibility to invest funds that would otherwise be held by the insurance carrier, potentially earning interest or investing in other areas of the business until claims need to be paid.

Customization of Benefits

Employers have the liberty to customize their health benefits to meet the specific needs of their workforce. Unlike standard insurance plans with one-size-fits-all coverage, an ASO arrangement allows employers to design benefits that align with their employee’s preferences and requirements. This flexibility enhances the value of the benefits to employees, contributing to higher satisfaction and retention rates.

Enhanced Cash Flow Control

Through ASO, employers maintain a tighter grip on their cash flow. With a conventional insurance plan, they pay fixed premiums regardless of the actual claims. ASO arrangements, in contrast, allow employers to only disburse funds as claims are filed, offering improved cash flow flexibility. This element is crucial for maintaining a healthy balance sheet and can also yield indirect cost savings due to improved liquidity and cash management.

Risk Management

When implementing an Administrative Services Only (ASO) plan, effective risk management strategies are critical. These strategies protect against financial uncertainties and mitigate potential high-cost claims that may impact the plan’s stability.

Stop-Loss Insurance Policies

Stop-loss insurance policies serve as a financial safeguard for employers who opt for ASO arrangements. These policies are procured to cap the employer’s payout for claims, thus transferring excess risk to the insurance carrier. Stop-loss insurance comes in two forms: individual or “specific,” which limits claim costs per individual, and aggregate, which sets a ceiling on the total claims the employer pays within a policy year.

Financial Risk Assessment

Employers must undertake a thorough financial risk assessment to determine their ability to shoulder potential claims. This involves evaluating historical claims data, assessing the health risk of the employee pool, and projecting future claims. A financial risk assessment helps quantify the employer’s exposure to risk and informs the level of stop-loss insurance required.

Catastrophic Claims Management

Catastrophic claims management is a critical component in ASO plans. It revolves around strategies to limit the financial impact of high-cost claims due to serious illnesses or accidents. Implementing thorough review processes and negotiating provider payment rates are part of managing catastrophic claims. Proactive health management and wellness programs can also reduce the incidence of high-cost claims over time.

Plan Administration

When it comes to Administrative Services Only (ASO), plan administration is a pivotal element, encompassing a range of services essential for managing employee benefit plans. These typically include claims processing and customer service excellence. Effective plan administration is critical for both companies and their employees, ensuring benefits are managed efficiently and with high satisfaction.

Claims Processing

In an ASO setup, the employer is responsible for funding the employees’ benefit plans but claims processing is managed by an external administrator. This process includes verifying the eligibility of claims, ensuring services are covered under the plan, and making accurate payments to healthcare providers. By hiring an external vendor, companies aim to leverage specialized expertise to minimize errors and streamline the claims process.

Customer Service Excellence

Customer service stands as a cornerstone of plan administration, with a direct impact on the satisfaction of the employees. An ASO agreement often includes access to dedicated customer service teams trained to address inquiries, resolve issues, and provide support regarding benefit plans. High-quality customer service in an ASO model involves timely response to questions, clear communication, and personalized assistance to enhance the overall employee experience.

Insurance Coverage Options

Employers seeking flexible solutions for their staff benefits consider Administrative Services Only (ASO) plans for their adaptability to company needs. These plans allow employers to fund the insurance coverage directly while outsourcing the management of these benefits to a third-party provider.

Health and Dental Benefits

With an ASO model, companies can provide health benefits such as medical, surgical, and hospital expenses coverage. Employers maintain control over the design and funding of the plan, which can lead to cost savings. They pay for dental benefits, covering preventive care like cleanings, basic procedures such as fillings, and major services, including crowns and bridges.

Health and Dental Benefits

Benefit TypeCoverage Example
HealthMedical exams, surgical procedures, hospital stays
DentalCleanings, fillings, crowns, orthodontics


Disability and Life Insurance Options

For long-term disability, an ASO plan allows for tailored coverage that protects employees in the event of a prolonged illness or injury. The employer typically decides the length of coverage and the percentage of the employee’s salary that will be provided. Life insurance options can include a base amount funded by the employer, with the possibility for employees to purchase additional coverage if they choose to.

Disability and Life Insurance Options

Plan TypeBenefit Description
Long-Term DisabilityA percentage of salary covered for extended illness or injury
Life InsuranceBase coverage with optional employee-funded additional insurance


Cost Containment Strategies

Effective cost containment is essential for self-insured entities utilizing an Administrative Services Only (ASO) plan. It is imperative to emphasize strategies that mitigate financial risks like anticipating claims and covering catastrophic losses while maintaining quality care.

Provider Network Leverage

ASO plans can reduce costs by negotiating favorable terms with a provider network. This approach often involves setting up discounted rates for services, which hinges on the volume of patients directed to those providers. Effective leverage is crucial for mitigating anticipated claims and reducing the overall financial burden on the self-insured entity.

Claims Data Analysis

Claims data analysis plays a pivotal role in understanding cost drivers and identifying trends that could lead to higher expenses. By meticulously evaluating past and current claims data, organizations can forecast anticipated claims and implement measures to prevent excessive costs. This data-driven strategy aids in spotting outliers that may indicate potential catastrophic losses or areas where costs can be reduced without compromising care quality.

Reserves Management

Proper reserve management ensures there are sufficient funds to cover anticipated claims and protect against catastrophic losses. Establishing and maintaining an appropriate reserve level is a balancing act that requires regular analysis and adjustments. The accuracy in predicting claims and the actuarial rigor applied in reserve estimation directly impact the financial stability of a self-insured ASO plan.

Legal and Regulatory Considerations

When companies choose an Administrative Services Only (ASO) model for their employee benefit plans, it is crucial to navigate the complex legal and regulatory landscape. This includes adherence to healthcare regulations and maintaining adequate financial reserves. These frameworks ensure both transparency and compliance in providing health benefits.

Compliance with Healthcare Regulations

Entities utilizing an ASO arrangement must ensure strict compliance with relevant healthcare regulations, such as the Health Insurance Portability and Accountability Act (HIPAA) and the Affordable Care Act (ACA). These regulations mandate the safeguarding of protected health information (PHI) and provide guidelines on benefits coverage. Noncompliance can lead to significant fines and penalties. Additionally, ASO providers must stay current with state-specific health insurance mandates that affect the administration of employee benefit plans.

Reserve Requirements

Under an ASO contract, the reserve requirements are critical for ensuring that sufficient funds are available to cover the cost of employee claims. Employers are responsible for setting aside a predetermined portion of funds, also referred to as reserves, to manage the fluctuating costs of health claims. The specific amount of reserves is typically determined by past claim history and actuarial projections to safeguard against the financial risk of high-cost claims. Maintaining adequate reserves is not only a prudent financial practice but also often a legal requirement to demonstrate fiscal responsibility.

Considerations for Employers

Employers considering an Administrative Services Only (ASO) plan need to navigate various factors to optimize their employee benefits while maintaining risk management and flexibility.

Sourcing the Right ASO Provider

Selecting a suitable ASO provider is crucial for large employers, as it directly impacts the efficiency and quality of their benefits administration. They must ensure that the provider has a robust track record of serving similar-sized companies, offering:

  • Expertise: Depth of knowledge in legal compliance and industry standards.
  • Technology: Advanced tools for benefits administration and data analysis.

Tailoring Plans to Employee Needs

ASO arrangements offer the flexibility to design benefits that align with employee preferences and company culture. Employers should:

  • Conduct surveys to understand what benefits are most valued.
  • Customize plans that cater to diverse employee demographics and needs.

Financial Implications

Managing the financial aspects of an ASO plan requires understanding both the potential cost savings and the risks involved. Employers must navigate the balance between cash flow concerns and the financial stability offered by a fully insured plan.

Budgeting for Health Costs

Employers adopting an ASO arrangement—with a stop-loss insurance policy as a safeguard—aim to better predict and budget for health costs. By directly funding employees’ health care expenses, they often save on premiums normally paid to an insurance company. However, they must be adept at cash flow management to ensure sufficient reserves for claim periods that have higher than anticipated expenses. The employer is responsible for the health costs of not only employees but also their dependents, which requires meticulous financial planning.

Impact on Employee Wages and Salaries

Introducing an ASO model can influence an employer’s compensation strategy. When employers save on health care costs, they may have more flexibility in adjusting wages and salaries. Nevertheless, they must consider that the ASO model places the financial risk of health claims on their balance sheet, which could lead to increased financial volatility. Employers with unpredictable claim rates may find this model challenging without robust stop-loss insurance to cap potential claims expenses.

ASO for Different Business Sizes

Administrative Services Only (ASO) arrangements vary in impact and implementation depending on the size of the business. They are tailored to meet the unique needs of different entities, with specific advantages and challenges for small businesses and distinct scalability aspects for large employers.

Pros and Cons for Small Businesses

Pros:

  • Small businesses can benefit from the lower costs associated with ASO plans, as they are only paying for administration and not the full insurance premium.
  • Group health self-insurance programs can give small businesses more control over their employee benefits, allowing for customization that fits their workforce.

Cons:

  • Small businesses face higher financial risk if claims exceed expected amounts, due to the lack of a larger insurance pool.
  • They may lack the bargaining power to negotiate with providers for lower costs compared to larger employers.

Scalability for Large Employers

Large employers often find ASO models highly scalable, adapting easily to their growing workforce and changing needs.

  • They can leverage their size to secure more favorable terms with vendors, reducing the costs associated with administering benefits.
  • Large employers have the capital reserves to buffer against high-claim periods, making the risk less than it is for small entities.

However, even large employers need to carefully assess their ability to predict and fund employee claims under an ASO model to avoid unforeseen expenditures.

Additional Benefits and Services

In the realm of Administrative Services Only (ASO) plans, additional benefits such as wellness programs and specialized health accounts offer substantial value to employees, often enhancing overall health outcomes and financial well-being.

Wellness Programs and Additional Services

Organizations that employ ASO arrangements frequently demand integrated wellness programs. Such programs may include preventive care, health assessments, and initiatives tailored to employee health improvement. They can mitigate costs by reducing overall healthcare claims. Providers of these programs often couple them with Preferred Provider Organizations (PPOs) because PPOs facilitate a wide network of doctors and hospitals, thereby offering employees preventative services at lower costs.

Supplemental Health Accounts

Employers may also offer Health Savings Accounts (HSAs) and Health Reimbursement Arrangements (HRAs) as part of their ASO plan. These accounts are designed to offer employees more control over their healthcare spending.

  • HSAs are a standout choice for employees enrolled in high-deductible health plans, allowing them to save pre-tax dollars for medical expenses.
  • HRAs, funded solely by the employer, provide reimbursement for out-of-pocket medical costs and personalized coverage over and above primary health plans.

Both accounts are instrumental in extending extended health benefits, covering additional expenses like prescription medication and dental care, thus providing a more comprehensive healthcare financial strategy.

Operational Execution

In Administrative Services Only (ASO) plans, operational execution is pivotal to the plan’s success, focusing rigorously on the specifics of handling claims and managing financial transactions. Precision in these areas is vital to maintaining a smooth operation and ensuring accurate record-keeping and payment distributions.

Handling Claims Incurred

Once a claim is incurred, especially in areas like dental care, the process requires detailed attention for verification and administrative action. Insured individuals submit their claims to the ASO provider, who then assumes the responsibility of:

  • Evaluating the claim for eligibility and coverage under the plan.
  • Confirming the accuracy of the claims against the plan details and the actual services rendered.

Accounting and Payment Processing

The ASO plan takes on the accounting and payment processing responsibilities which involve:

  • Recording all financial transactions related to the claims incurred.
  • Ensuring payments are issued to service providers promptly and accurately.
  • Reconciling accounts to reflect the actual expenses, thus maintaining transparent financial records for the employer.

Evaluating Success

In the context of Administrative Services Only (ASO) plans, success is multifaceted, encompassing both the granular oversight of plan performance and the overarching objective of employee satisfaction.

Monitoring Plan Performance

Employers must actively monitor their ASO plan performance to ensure not only financial stability but also the efficacy of the services provided. Regular analysis of claims data is critical, as it reveals the usage patterns and can prompt strategic adjustments where necessary. For instance, the frequency and cost of short-term disability claims can significantly affect the operational budget and require specific attention.

  • Key Metrics to Track:

    Average cost per claim
    Number of claims processed
    Turnaround time for claim settlement

Employers should also examine customer service metrics, as prompt and supportive service is crucial for the management of an ASO plan.

Assessing Employee Satisfaction

The second crucial component of evaluating an ASO plan’s success lies in gauging employee satisfaction. Employee feedback is pivotal because it directly relates to the plan’s practicality and the effectiveness of health benefits management.

  • Methods for Assessment:
    Surveys and questionnaires
    Focus groups
    Direct feedback mechanisms

An employer should pay close attention to feedback concerning the ease of navigating claims processes and the quality of customer support received during the management of short-term disability cases. These insights help tailor the ASO plan to better meet the needs of employees.

Article By
Managing Editor
Milly is an international lawyer and tech entrepreneur who has advised companies on expanding globally for over 5 years. She is an advocate of remote hiring and regularly consults on future of work matters. Milly founded RemotePad to help employers learn more about building and growing international teams.

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