FABOH Plan

Background

The FABOH Plan is a preferred provider network health care plan design. It is sponsored and managed by the Fond du Lac Area Businesses on Health, Inc., (FABOH). The effective date of the FABOH Plan described below is October 11, 2010.

FABOH sponsors the FABOH Plan in the Wisconsin counties of Fond du Lac, Sheboygan, Green Lake, Dodge, Winnebago, and Washington (FABOH's Service Area). The FABOH Plan has been adopted by all FABOH Full Access Employer Participants and all FABOH contracted providers. The FABOH Plan is marketed to employers and other groups in FABOH's Service Area. The FABOH Plan ensures quality medical care through local development of medical management programs and educational programs for providers and employers.

FABOH enters into Participating Provider Agreements with health care providers who agree to provide health care services and obtain reimbursement under the terms of such agreements and according to the terms of the FABOH Plan. The FABOH network of providers is called the FABOH Network, and each such provider is called a Network Provider.

FABOH enters into Full Access Employer Participant Agreements with its employer participants and other purchasers of health care services for employer sponsored health plans. Parties to these agreements gain access to the FABOH Network and Network Providers in consideration for their agreement to abide by the terms of the FABOH Plan. Employers and other purchasers of health care services are called Payers, their health plans are called Benefit Plans, and their employees or other beneficiaries of such plans are called Beneficiaries.

Plan Design

The FABOH Plan offers three tiers of channeling incentives for Beneficiaries of Payers’ Benefit Plans. These incentives encourage Beneficiaries to use the services of Network Providers rather than the services of providers who are not in the FABOH Network, who are called out-of-network providers. Beneficiaries are encouraged, and thus channeled; to Network Providers because their co-pay obligations, deductible amounts, and out-of-pocket maximums are lower when using a Network Provider than when using an out-of-network provider.

Payers who access the FABOH Network select one of the three tiers for their Benefit Plan. Payers may not select one tier for one Network Provider and another tier for another Network Provider, nor include in their Benefit Plans any incentives to encourage use of one Network Provider over another Network Provider. Payers have the benefit of Network Provider fee schedules set according to the tier selected. Beneficiaries have the benefit of lower co-payment amounts, deductibles, and out-of-pocket maximums set according to the tier selected.

Network Providers are willing to accept lower fees for their services in return for an anticipated greater number of patients who select them as a result of the channeling incentives of the FABOH Plan.

FABOH Plan 3 Tiers
Payers select one of the following tiers for their Benefit Plans:

Tier 1 Tier 2 Tier 3

The differential between a Beneficiary's co-pay obligation for out-of-network providers and Network Providers is at least 10%.

The differential between a Beneficiary's co-pay obligation for out-of-network providers and Network Providers is at least 20%.

The differential between a Beneficiary's co-pay obligation for out-of-network providers and Network Providers is at least 30%.

A Beneficiary's deductible for out-of-network providers is recommended to be at least 1.5 times that for Network Providers for single and family plans.

A Beneficiary's deductible for out-of-network providers must be at least 1.5 times that for Network Providers for single and family plans.

A Beneficiary's deductible for out-of-network providers must be at least 1.5 times that for Network Providers for single and family plans.

Beneficiary's out-of-pocket maximum for out-of-network providers recommended to be at least 1.5 times that for Network Providers for single and family plans.

Beneficiary's out-of-pocket maximum for out-of-network providers must be at least 1.5 times that for Network Providers for single and family plans.

Beneficiary's out-of-pocket maximum for out-of-network providers must be at least 1.5 times that for Network Providers for single and family plans.

Payer pays Network Providers for services at fees determined by FABOH for Tier 1, or as otherwise negotiated for Tier 1 by FABOH and Provider.

Payer pays Network Providers for services at 95% of Tier 1 fees.

Payer pays Network Providers for services at 90% of Tier 1 fees.

For example, the Benefit Plan of a Payer provides that Payer pays 80% of the co-pay amount for the services of an out-of-network provider, but 90% of a Beneficiary's co-pay amount for the services of a Network Provider.

Use of Other Providers and Networks

Payers may provide access in their Benefit Plans to other providers and other networks, subject to the requirements set out below.

1. Outside of FABOH Service Area: Payers may include providers and networks that provide health care services from outside of FABOH's Service Area but not within, without restriction.  Usually this is done to enable Beneficiaries who live or work outside of FABOH's Service Area to obtain health care outside of FABOH's Service Area.

2. Within FABOH Service Area: Payers also may include providers and networks that provide health care services within FABOH's Service Area, but only if their Benefit Plans meet the following requirements, as applicable:

  • Providers who are not Network Providers must be defined as out-of-network providers in the Benefit Plan with respect to the services they provide within the FABOH Service Area, thus maintaining co-pay amounts for the services of such other providers within the FABOH Service Area at levels at least 10% greater than for those of Network Providers in tier 1.
  • In the alternative, providers who are not Network Providers but are providers in another network may be offered in the Benefit Plan according to the terms of such other network plan, provided that Beneficiaries are required to select only one network of providers from which they obtain their health care services within the FABOH Service Area, either the FABOH Network of providers, or another network of providers.  The Benefit Plan must not allow Beneficiaries to select individual providers from a menu of providers of multiple networks.  In addition, the Payer must ensure that claims from Beneficiaries for services provided by a provider be sent only to the network selected by the Beneficiary, and that member ID cards issued by the Benefit Plan to the Beneficiary clearly show the network selected by the Beneficiary.
  • Providers who are both a Network Provider and a provider in other networks may be offered in the Benefit Plan for services to be provided within the FABOH Service Area, but only according to the terms of the FABOH Plan.  Beneficiaries must not be able to use the services of such providers according to the terms of the other plan, nor may Payers pay according to the fee schedule of the other plan.  Payer must ensure that claims from Beneficiaries for services provided by such providers be sent only to FABOH, and that member ID cards issued by the Benefit Plan to the Beneficiary clearly show the FABOH Network for such provider.