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HOW RBP Limits Are Set


#1: Plan finds out the Medicare allowable prices for treatments and procedures

#2: Plan marks up Medicare allowable prices to a specific level

#3: Maximum coverage amounts are determined for each procedure and treatment

•RBP limits are known price increases with a known starting price

•99 percent of the time, prices are based on Medicare coverage

•Nearly all doctors and facilities already take Medicare, so we are using a starting price we know the providers already accept every day

•Doctors and hospitals report procedure and treatment costs to Medicare, and Medicare marks those prices up for profit

•RBP traditionally takes that known profitable starting price, and marks it up yet again

•Actual markups depend on employer risk tolerance, geographic areas of employee populations, and if any networks or direct contracts are also involved

RBP in Action


#1: Plan participant goes to get treatment

#2: Plan sponsor covers specified amount

#3: Plan participant pays any remaining balance beyond maximum coverage amount

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