Let’s face it: Health insurance isn’t exactly what many people would classify as “exciting reading.” It’s typically buried inside HR handbooks, confusing as hell, and something you only consider when you really, really need it.Meritain Health
But here’s the thing—knowing something about the companies that operate below all that healthcare noise, like Meritain Health, can have a profound effect on how you access medical care, keep costs under control, and even keep employees smiling (if you’re the boss). And Meritain is not your faceless insurance company. They are Third Party Administrators (TPA) with a twist, and that’s a good thing.Meritain Health
So pour yourself a coffee, and let’s jump right in to this point-by-point, blog-style deep-dive into who Meritain Health are, what they do, and why it should matter to you.
A Little History: Where Did Meritain Health Come From?
Meritain Health didn’t appear out of thin air. This company has been in business since the early ’80s. It was first established in 1983 under the name North American Health Plans, later rebranding to become Meritain Health in 2006.
The big power move, though, came in 2011, when they joined Aetna, a giant of American health insurance. Fast forward to 2018, and Aetna was bought by CVS Health — as in, that CVS. So now Meritain is nestled in an environment where deep roots exist in pharmacy, clinical care, wellness and yes, insurance.
Why does this matter? Because Meritain gets to act like an agile, bespoke service firm with the clout and deep resources that come from being arm-in-arm with a health care giant. Best of both worlds.
What Exactly Does Meritain Health Do?
Meritain Health: This is a Third Party Administrator – aka they’re not the ones insuring you the way Blue Cross or UnitedHealthcare would. Instead, they administer health benefits for companies that wish to self-fund their plans.
Hold on … What’s a Self-Funded Plan?
Great question. A self-funded health plan occurs when your employer directly pays the medical costs or hospital bills, instead of purchasing insurance from an insurance carrier. It’s basically eliminating the middleman — but with a smart and experienced guy to make sense of the chaos (which is where Meritain comes in).
So here’s what companies do teaming up with Meritain:
Formulate personal health plans
Adjudicate medical and pharmacy claims
Handle customer service
Negotiate provider networks
Provide wellness & chronic condition management
Give employees digital tools
They are drivers, organizers, facilitators of everything between the employer, the employee, the doctor and the pharmacist.
The Core Services Breakdown (Minus the Corporate Fluff)
So let’s break down their biggy offers — but we’ll cut to the chase:
Customized Benefits Plans
Think of Meritain as your healthcare tailor. Not: “What can we do for all companies?” but “What do we need?” racing driver-style suit. What’s your budget? What kind of health care culture do you want?
They would then assist companies in creating a plan from scratch, which could cover:
Medical coverage
Dental & vision
Disability & life insurance riders
Telehealth
Employee Assistance Plans (EAPs)
Mental health coverage
Prescription benefits
It’s that kind of flexibility that has so many of the mid-size and larger employers moving off the old insurance and heading towards TPAs like Meritain.
Aetna’s Network (Yes, It’s a Big Deal)
One of the big flexes Meritain offers is its Aetna provider network. “Which means Meritain covered employees can see a lot of doctors across the country — without the crazy out-of-pocket surprises.”
If you’ve ever played the “is this doctor in my network?” game, you know how precious that is.
The term Pharmacy Management (PBM)
Rx costs are through the roof, and everybody knows that’s where a giant pile of their health care dollars goes.
Smart pharmacy solutions from Meritain include:
Formulary Control (aka: generics from cheaper to cheapest)
Medication adherence programs
Specialty drug management
Transparent pricing
They also draw upon CVS Caremark (because CVS owns Aetna), so there is a built-in advantage when it comes to saving costs and delivering integrated care.
Wellness & Disease Management
Healthy workers = less claims, the less expensive it is. Wellness programs provided by Meritain include:
Biometric screenings
Health coaching
Incentive programs
Smoking cessation
Calories counting and sports monitoring
On the disease side of things, they help people manage chronic conditions — diabetes, asthma, heart disease — by connecting them with case managers who lead them through the health care labyrinth.
Tech That Doesn’t Drive You Crazy
Let’s face it: Some healthcare portals are as clunky and outdated as a fax machine. Meritain, thankfully, has some pretty solid tech for the members and the employers:
Easy to use member portal (check on claims, deductible, print ID cards)
Mobile app access
Electronic EOBs (explanation of benefits)
Cost estimation tools
Employer reporting dashboards
At a basic level, you can see what’s going on, keep track of your health plan and not call HR every five minutes. That’s a win.
Mental Health Matters (and Meritain Gets That)
Mental health has become not just a “nice to have” but nonnegotiable since the pandemic. Another company that is diving into this space in a real way is Meritain Health, through a partnership with Telemynd, a virtual mental health provider.
Employees get access to:
Virtual therapy sessions
Psychiatry evaluations
Medication management
Quick easy appointment process (3 months wait?)
And these services are available under most Meritain plans, so you will be able to use them, too.
Real Wins and Success Stories from My Clients
Meritain’s approach isn’t only talk. Many companies report:
Reduced claims costs resulting from superior network rates
46 Healthier work force from wellness incentives
Happier HR departments because there is less of them drowning in admin work
High member satisfaction (typically exceeds that of traditional insurers)
Here’s a simplified example: A school district moved to Meritain and achieved more than $1 million in savings in the first year while protecting the strong coverage it provides to its teachers and staff. A second faced that challenge and went on to reduce pharmacy spend 20% through improved formulary design.
Who is Meritain Health Good For?
You or your family will find that Meritain Health isn’t the ideal benefit plan for everyone. For a solo freelancer in search of a bare-bones health plan, this isn’t the lane for you. But if you’re:
A business 50+ employees
Want to be able to self-fund your plan
Seeking to control costs more closely
Sick of one-size-fits-all health plans
Seeking a flexible partner, not a static and predictable insurer
…then Meritain is certainly one to look into.
Where Does Meritain Fit in the Larger Health Care System?
Healthcare is shifting—fast.
Employers want more control.
Workers call for stronger mental health and digital services.
Prices continue to soar, and transparency is king.
Meritain Health is capitalizing on that momentum by providing services that:
Mix personalized service with major-league resources
Reducing without dumbing down
Take care of your employees (body + mind)
Match consumer-driven trends
In an environment where health care is increasingly moving towards value-based models and smarter care choices, TPAs such as Meritain are the unsung leaders of the pack.
The Future of Meritain Health: What Comes Next?
With health care reform, AI integration, digital health apps, everywhere-you-turn, you might ask, what’s next for a company like Meritain?
They’re also will double down on:
Data analytics to enable employers to anticipate cost spikes
Seamless connection with wearables for the monitoring of health parameters in real time
More mental health, more telehealth
Health equity programs rooted in DEI
Wellness connected green initiatives in healthcare has their bonuses for wellness in the medical care benefits (=”)
As a part of CVS Health, Meritain has a direct view into every major healthcare innovation on the horizon.
Final thoughts: Is Meritain Health worth it?
If you’re covered by Meritain as an employee:
Use their tools. Participate in wellness programs. The mental health options are not to be disregarded. They actually help.
If you are an HR leader or business owner:
Self-funding with a TPA like Meritain could be a budget saver, and keep your employees happy. It’s worth a serious look.
If you’re just trying to get a feel for the healthcare landscape:
Meritain is evidence that flexible, transparent and smarter benefits can exist — even in the typically clunky industry.
For more interesting topics visit WISENEWS, QUALITYINFO & ZEPBOUND
