Date: Feb 02, 2014
February 2014: The PACA Is Here to Help

Pinnacle Claims Management, Inc., the wholly owned third party health insurance administrator of Western Growers, has expanded its scope and is operating under a three-year contract to provide administrative services for California’s health insurance exchange.

Under national health care reform and the Affordable Care Act that established it, each state was given the opportunity to create its own health insurance exchange, both for individuals and for small businesses.  While many states turned down that opportunity and are operating under the umbrella of the federal health insurance exchange, California did launch its own program called Covered California.

As designed, Covered California allows individuals, as well as small businesses with one to 50 eligible employees, to access health care insurance options through the internet.  In March of 2013, Covered California began the process of contracting with private companies to provide some of those administrative services.  Pinnacle Claims Management was awarded a three-year contract to provide some of these services for the Small Business Health Options Program, also known as SHOP.

“We looked at the RFP (Request for Proposal) and noted that it mirrored our core competencies as a third party administrator (TPA),” said David Zanze, president of Pinnacle Claims Management.

As a TPA for many years, Pinnacle has been offering similar administrative services to many companies in the produce industry that are self-insured.  “The RFP called for the provision of many services that we are currently providing and that we are very good at,” he said.  “We run a call center, we offer sales support and training.  We are good at those things.”

Under its SHOP contract, Pinnacle Claims Management is basically working with the insurance agent community to offer options to small business owners that want to cover their employees through Covered California.

Many small businesses already have insurance agents that they work with and now with Covered California these companies are turning to those agents to explore their health insurance options.  In turn, those agents are turning to Pinnacle Claims Management for help with that work.

“We provide many services,” said Zanze.  “In the first place, each agent must go through training and be certified so that he or she can offer these options.  We help agents with the administrative process to get certified once they have completed the training.”

Zanze said the Pinnacle staff can work with the agent establishing enrollment eligibility for the small business and even do the keystroke entry of enrollment applications.  “We can provide almost any service the agent needs to enroll that company,” said Zanze, “including reconciliation of the account and provide answers around the payment of the commission to the agent.”

Zanze said there is a great incentive for small businesses to offer health insurance to their workers and some businesses and agents are not up to speed on these incentives.  He said tax credits of up to 50 percent of the premium cost are available to the employer if they meet specific criteria.

For Pinnacle Claims Management, Zanze said the contract with Covered California helps the company create many economies of scale.  “It simply gives us more resources to provide the many services we offer to all of our clients.  It is a win-win situation,” he added.

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