Elevating
Care.
Reducing
Cost.
A comprehensive proposal for Karen Kane, Inc.
Executive Summary
For years, Karen Kane, Inc. has provided employees with generous benefits through a traditional, fully-insured plan. However, this model has led to a familiar cycle: significant premium growth that outpaces your actual claims experience. If you don't take control of your health plan, you will continue to be subject to unpredictable, double-digit increases. Health365+ offers a fundamentally better model that provides immediate savings while controlling long-term costs, projecting a five-year savings of over $1.7 million compared to staying on your current path.
A Journey Reimagined
Health365+ is built on a different idea: real support should feel personal, accessible, and proactive. We're on a mission to transform health coverage from a frustrating maze into an experience that is guided, transparent, and genuinely helpful for everyone.
Our Philosophy: A Fundamentally Better Approach
A True Concierge Experience
We provide a dedicated, human-first point of contact for every member, moving beyond call centers to build real relationships and provide expert guidance.
Improving Health to Reduce Costs
Our model is designed to address the root cause of claims. By proactively engaging members to manage and improve their health, we deliver better outcomes and generate sustainable, long-term savings for your plan.
Human-Centric Technology
We leverage powerful, integrated digital tools not to replace human interaction, but to enhance it. Our apps and platforms free our care teams to focus on what matters most: your people.
Our Integrated Care Model
This is how we deliver better care and lower costs. Our model isn't a set of disconnected services; it's one intelligent system that connects technology, data, and human expertise to proactively guide members at every turn.
Care Coordination System
1. AI-Powered Pre-Certification
Our pre-auth service, powered by an AI engine and reviewed by clinicians, dramatically accelerates approvals. This eliminates frustrating delays and creates critical data for our care team.
2. Proactive Clinical Outreach
The moment a procedure is approved, the data alerts the member's dedicated health coach. They don't wait for a call; they reach out immediately to begin care coordination.
3. High-Value Care Guidance
The coach guides the member to the best in-network providers, schedules appointments, and arranges follow-up care. This ensures a better experience, improved outcomes, and lower costs for the plan.
This isn't just about speed; it's about intelligence. Every administrative step is transformed into a proactive care opportunity, ensuring better care, a better experience, and lower costs.
The Coordinated Care Difference
In traditional healthcare, members are often left alone to navigate a web of disconnected providers, labs, and pharmacies. There's no central "quarterback" to manage their care. We solve this problem by acting as the single, reliable hub for all of a member's health needs.
Typical Member Journey
Fragmented, confusing, and stressful.
Member feels unwell and is unsure where to go.
Calls multiple doctor's offices to find an in-network provider and schedule.
Is responsible for coordinating between PCP, specialist, lab, and pharmacy.
Spends hours on hold with the insurance carrier to understand bills and coverage.
Health365+ Coordinated Journey
Unified, proactive, and simple.
Member contacts their dedicated Health365+ Care Team.
Care Team finds the right in-network provider and schedules the appointment.
Care Team coordinates pre-authorizations, specialist referrals, and prescriptions.
Member has one point of contact for all questions, resulting in a simple, stress-free experience.
Core Plan Services
The integrated flow is powered by these foundational services, designed to provide comprehensive support across all aspects of care.
Virtual Direct Primary Care (DPC)
The digital front door to our system. For a $0 copay, members get unlimited, on-demand access to a dedicated care team for acute issues, chronic condition management, wellness visits, and prescription renewals.
Proactive Chronic & Whole-Health Management
Using data from across the ecosystem, we identify at-risk members and engage them with a health coach and no-cost remote monitoring devices. This program is proven to save over $2,000 per engaged member annually.
A Conflict-Free Pharmacy Model
We fundamentally redesign pharmacy benefits to eliminate conflicts of interest. For high-cost specialty medications, our TPA will work with members to utilize Manufacturer/Patient Assistance Programs. Any remaining claim funds at the end of the year are returned to you.
The Health365+ Digital Hub
We empower members and administrators with a unified, intuitive technology platform that simplifies benefits and enhances the human-powered support our care teams provide.
Your Central Hub for Digital Support
Our platform provides a single point of access for all plan-related information and tools, eliminating the confusion of multiple logins and disconnected systems. It's the central hub for a member's entire health journey.
"We believe technology should simplify the healthcare journey, not complicate it. Our platform provides the clarity for transparent decisions while always keeping the member at the heart of a human-centric experience."— Joshua Parise, Chief Innovation Officer
A Better Benefits Experience
We believe that a health plan is only as good as an employee's ability to understand and use it. We lift the burden of benefits education from your HR team by providing direct, expert support to your employees.
Guided Enrollment with Licensed Coaches
We provide your employees with direct access to our team of salaried, licensed benefit coaches. During open enrollment, our coaches can walk each employee through their options and complete their benefit elections over the phone or via a co-Browse session. This hands-on approach limits costly enrollment errors, gives valuable time back to your HR department, and dramatically increases employee understanding of how to select and use the right plan for their family.
BenefitBites: On-Demand Education
We make complex benefits simple with our library of short, interactive "BenefitBites" courses. These communications are sent directly to employees via SMS or email both pre- and post-enrollment to teach them how to use their plan effectively. Each course is custom-built for your benefits package, ensuring your team gets the specific information they need, when they need it.
Voices of Our Members
Here’s what employees have to say about their experience with the Health365+ model.
"With my old plan, I felt like a number. I'd spend hours on hold trying to get answers. The first time I called Health365+, I spoke to a real person who knew my name and actually solved my issue in minutes. The difference is night and day."
"Managing my diabetes used to be a constant struggle. With Health365+, they sent me a free glucometer that syncs with their app, and my health coach, Emily, checks in regularly. I feel more in control of my health than ever before."
"I was so stressed when my daughter got sick, but our Health Coach, Maria, was incredible. She helped us find a top-rated pediatrician in our network and even scheduled the appointment for us. It was a huge weight off my shoulders."
Three Strategic Options for Karen Kane
We have designed three distinct plan strategies to give you maximum flexibility. You can choose to upgrade your benefits, match your current offering while improving it financially, or maximize your premium savings with our innovative GAP plan.
From Passive Payer to Empowered Owner
| Aspect of Your Plan | Typical Fully Insured Plan (Cigna) | The Health365+ Model |
|---|---|---|
| Access to Claims Data | A "black box" where data is owned and hidden by the insurer. | Full Transparency. Access your plan's data to see exactly where your dollars are going. |
| Unused Claim Dollars | Forfeited. The insurance carrier keeps all unused premium dollars as profit. | 100% Retained. You keep every dollar in your claims fund that isn't spent on care. |
| Plan Design & Flexibility | "One-size-fits-all" menu of off-the-shelf designs. | Designed by you, for you, with the flexibility to meet your workforce's specific needs. |
| Financial Control & ROI | Unpredictable annual increases with no real control over costs. | Strategic Cost Management. Finally manage the root cause of costs: member health. |
Option A: Gold H202
PPO cost control model with lower total exposure than Cigna.
$784,719 / year
- Deductible: $3.25k / $6.5k
- OOP Max: $3.25k / $6.5k
- 0% Coinsurance After Deductible
Option B: Gold H203
PPO upgrade plan with lower deductible and OOP Max.
$819,978 / year
- Deductible: $1.5k / $3k
- OOP Max: $3k / $6k
- 0% Coinsurance After Deductible
RECOMMENDED
Option C: Bronze H405 + $8K GAP
The lowest premium cost with the power of our GAP protection.
$697,333 / year
- Plan Deductible: $8k / $16k
- GAP pays first $8,000 of costs
- Member has $0 cost for most services
- Maximum possible premium savings
Side-by-Side Plan Comparison
Comparison for Cigna LocalPlus Members
| Feature | Current: Cigna LocalPlus | Proposed: Gold H202 (A) | Proposed: Gold H203 (B) | Proposed: Bronze + GAP (C) |
|---|---|---|---|---|
| Member Deductible | $250 / $750 | $3,250 / $6,500 | $1,500 / $3,000 | $0 (with GAP) |
| Member OOP Max | $5,000 / $10,000 | $3,250 / $6,500 | $3,000 / $6,000 | $0 (with GAP) |
| PCP / Specialist Visit | N/A | $30 / $50 | $35 / $55 | $50 / $120 |
Comparison for Cigna OAP Members
| Feature | Current: Cigna OAP | Proposed: Gold H202 (A) | Proposed: Gold H203 (B) | Proposed: Bronze + GAP (C) |
|---|---|---|---|---|
| Member Deductible | $250 / $750 | $3,250 / $6,500 | $1,500 / $3,000 | $0 (with GAP) |
| Member OOP Max | $5,000 / $10,000 | $3,250 / $6,500 | $3,000 / $6,000 | $0 (with GAP) |
| PCP / Specialist Visit | 100% | $30 / $50 | $35 / $55 | $50 / $120 |
Detailed Rate & Savings Analysis
| Plan | Tier | Lives | Rate PMPM | Total/mo | Total/yr |
|---|---|---|---|---|---|
| Cigna LocalPlus | |||||
| EE Only | 51 | $787.32 | $40,153.32 | $481,839.84 | |
| EE+Spouse | 1 | $1,653.41 | $1,653.41 | $19,840.92 | |
| EE+Child | 1 | $1,496.01 | $1,496.01 | $17,952.12 | |
| Family | 6 | $2,362.06 | $14,172.36 | $170,068.32 | |
| Cigna LocalPlus Total | $57,475.10 | $689,701.20 | |||
| Cigna OAP Base | |||||
| EE Only | 2 | $885.20 | $1,770.40 | $21,244.80 | |
| EE+Spouse | 1 | $1,858.85 | $1,858.85 | $22,306.20 | |
| EE+Child | 1 | $1,681.82 | $1,681.82 | $20,181.84 | |
| Cigna OAP Base Total | $5,311.07 | $63,732.84 | |||
| Cigna OAP Choice | |||||
| EE Only | 8 | $907.56 | $7,260.48 | $87,125.76 | |
| EE+Spouse | 1 | $1,905.91 | $1,905.91 | $22,870.92 | |
| Family | 1 | $2,722.79 | $2,722.79 | $32,673.48 | |
| Cigna OAP Choice Total | $11,889.18 | $142,670.16 | |||
| ALL CIGNA PLANS - GRAND TOTAL | $74,675.35 | $896,104.20 | |||
| Gold H202 (Health365+) | |||||
| EE Only | 61 | $760.18 | $46,371.00 | $556,452.00 | |
| EE+Spouse | 3 | $1,456.33 | $4,368.99 | $52,427.88 | |
| EE+Child | 2 | $1,167.73 | $2,335.46 | $28,025.52 | |
| Family | 7 | $1,759.69 | $12,317.83 | $147,813.96 | |
| Gold H202 Total | $65,393.28 | $784,719.36 | |||
| Gold H203 (Health365+) | |||||
| EE Only | 61 | $789.47 | $48,165.67 | $577,988.04 | |
| EE+Spouse | 3 | $1,541.31 | $4,623.93 | $55,487.16 | |
| EE+Child | 2 | $1,229.63 | $2,459.26 | $29,511.12 | |
| Family | 7 | $1,868.95 | $13,082.65 | $156,991.80 | |
| Gold H203 Total | $68,331.51 | $819,978.12 | |||
| Bronze H405 + $8K GAP | |||||
| EE < 65 | 55 | Base $579.07 GAP $87.21 → $666.28 | $36,645.40 | $439,744.80 | |
| EE 65–70 | 6 | Base $579.07 GAP $190.31 → $769.38 | $4,616.28 | $55,395.36 | |
| EE+Spouse | 3 | Base $1,108.05 GAP $156.95 → $1,265.00 | $3,795.00 | $45,540.00 | |
| EE+Child | 2 | Base $892.02 GAP $154.50 → $1,046.52 | $2,093.04 | $25,116.48 | |
| Family | 7 | Base $1,341.81 GAP $224.10 → $1,565.91 | $10,961.37 | $131,536.44 | |
| Bronze H405 + GAP Total | $58,111.09 | $697,333.08 | |||
| Grand Total & Savings | Total Annual | Savings | % Savings |
|---|---|---|---|
| Cigna Renewal | $896,104.20 | — | — |
| Gold H202 | $784,719.36 | $111,384.84 | 12.4% |
| Gold H203 | $819,978.12 | $76,126.08 | 8.5% |
| Bronze + $8K GAP | $697,333.08 | $198,771.12 | 22.2% |
A Stronger, Smarter Network
Health365+ offers a superior network strategy that unlocks access to world-class hospitals in Los Angeles, resolving a critical deficiency in your current Cigna LocalPlus plan. Our base is the HPN National PPO, and we wrap it with the PHCS/Multiplan network to provide robust nationwide coverage.
Los Angeles Hospital Access: Before & After
Cedars-Sinai Medical Center
World-Renowned Care
Cigna LocalPlus
❌ OON
Health365+
✓ In-Network
UCLA Medical Center
Top-Ranked Specialists
Cigna LocalPlus
❌ OON
Health365+
✓ In-Network
Keck Medicine of USC
Academic Medical Center
Cigna LocalPlus
❌ OON
Health365+
✓ In-Network
City of Hope
Leading Cancer Center
Cigna LocalPlus
❌ OON
Health365+
✓ In-Network
Children's Hospital (CHLA)
Pediatric Specialty Care
Cigna LocalPlus
❌ OON
Health365+
✓ In-Network
Providence Hospitals
St. Joseph / St. John's
Cigna LocalPlus
✓ In-Network
Health365+
✓ In-Network
GAP Strategy: Financial Protection
The recommended plans become powerful when paired with a GAP solution. This supplemental benefit "wraps" the deductible, protecting your employees from high out-of-pocket costs.
Full First-Dollar Wrap
This GAP benefit provides a full "first-dollar" wrap of the primary plan's deductible. It reimburses all member cost-sharing for major medical events from the very first dollar, effectively eliminating the deductible for those services.
How the GAP Works: Real-World Example
Scenario: Inpatient Stay
Plan: Max Savings (Option C)
The $8K GAP plan covers the member's entire deductible and out-of-pocket responsibility for this event.
GAP Rate Details
| Deductible | EE | ES | EC | EF |
|---|---|---|---|---|
| $1,000 | $16.79 | $30.22 | $29.73 | $42.82 |
| $1,500 | $25.19 | $45.33 | $44.59 | $64.23 |
| $2,000 | $33.58 | $60.45 | $59.46 | $85.64 |
| $2,500 | $41.98 | $75.56 | $74.32 | $107.05 |
| $3,000 | $50.37 | $90.67 | $89.18 | $128.46 |
| $5,000 | $59.97 | $107.93 | $106.25 | $154.12 |
| $8,000 | $87.21 | $156.95 | $154.50 | $224.10 |
Our Partnership Pledge
Choosing Health365+ is the first step in transforming your healthcare into a strategic benefit. We are not a vendor; we are an extension of your team, and our success is measured by your success.
Our Pledge to You, the Employer
- We pledge absolute transparency. You will have the access to the data you need to make informed decisions.
- We pledge a proactive partnership. We will bring you data-driven insights and strategic recommendations to continually improve the health of your population and the value of your investment.
- We pledge to deliver a measurable return. We are committed to improving health outcomes that result in lower costs and a more productive workforce.
Our Pledge to Your Employees
- We pledge to always be a compassionate, human-first point of contact. You will be treated with dignity and respect by a care team that knows your name.
- We pledge to be your trusted health advocate. We will help you navigate the complexities of the healthcare system, coordinating care between your providers.
- We pledge to empower you. We will provide the tools, information, and on-demand coaching support you need to achieve your personal health goals.
Jeremy Spreitzer
Chief Executive Officer
Joshua Parise
Chief Innovation Officer
Select Your Plan
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