Physician Partners Health Plan of the
Northshore is considered Single Employer Trusts (SET).
WHAT IS A SET?
SET programs provide health coverage to small employer groups including
nationally recognized franchise
and association groups.
A SET PROGRAM…
• uses nationally recognized and A-rated carriers for stop
• uses nationally recognized actuaries.
• uses nationally recognized TPAs.
• each employer group is individually underwritten.
Why would a SET Health Plan Be Right for Your Company?
• Lower cost than prevailing community PPO plans.
• All financial and insurance risk shifted to other entities.
• Individually underwritten for unique consideration.
A SET Plan…
• acts as a fully-funded health plan in the eyes of the federal
government as it establishes a self-funded medical benefit plan for each member
employer and as a result, is not subject to MEWA regulations.
• is a self-funded health plan in terms of group benefit administration
in accordance with ERISA and as such is not subject to state mandates.
• is a self-funded health plan in which the first 90% of the contribution
is used to pay claims directly and the remaining 10% of the contribution is
used to purchase stop loss coverage and to pay all other costs of the plan.
• as a result of the stop loss coverage the employer is not at risk beyond
contributions paid and in the event that medical utilization did not use all of
the first 90% of contribution, it would be applied to the following year's
• insures small employer groups of 5 or more employees, treating each
employer group individually, underwritten separately and with separate trust
accounts for each employer.
• follows and complies with ERISA regulations.
• is a self-funded plan, eliminating the cost of state premium tax.
• has multiple benefit plans including Gold Plan (80/60) and Platinum
Plan (90/70); each with a series of deductible and pharmacy benefit options to
choose from; and a wellness benefit.
• provides “takeover benefits” with prior group coverage,
meaning that if the member/condition was covered under a prior group health
plan, it will be covered by the SET Program.
• protects the financial integrity of the individual employer health
plans by underwriting each member company on its own risk factors.