POET LLC

ERISA Plan vs. Third-Party Administrator (TPA)

🎯 ERISA Plan vs. Third-Party Administrator (TPA)
They’re not the same thing — and mixing them up causes a LOT of confusion.

🌈 Think of it like this:

🏛️ ERISA Plan = The Rulebook

This is the actual health plan created by the employer.

It spells out:

✔️ What’s covered
✔️ What’s excluded
✔️ How claims should be paid
✔️ Who has final authority

📌 The employer owns the ERISA plan and carries the responsibility.

⚙️ Third-Party Administrator (TPA) = The Referee

They simply:

✔️ Process claims
✔️ Apply the plan rules
✔️ Handle paperwork & customer service

📌 The TPA follows the rules — they don’t make them

💡 Why this matters:
👉 An ERISA plan can change TPAs
👉 A TPA cannot change the ERISA plan
👉 Coverage decisions come from the plan document, not the administrator

✨ Bottom line:
🧠 ERISA Plan = The Authority
🛠️ TPA = The Administrator

Understanding the difference protects employers, providers, and members alike.

Disclaimer: The information provided in this blog is for general educational purposes only. While Ink strives to explain insurance concepts accurately and clearly, payer rules, contracts, and policies can vary widely by plan, state, and provider agreement—and they change frequently.

This content should not be interpreted as definitive guidance or a substitute for reviewing payer manuals, contracts, or official communications. Physician offices are encouraged to conduct their own research and verify requirements directly with the applicable insurance carriers before making operational or billing decisions

NEW BCBSTX fee schedule coming

ATTENTION PROVIDERS

BCBSTX has notified POET that a NEW Fee Schedule for Blue Choice and Blue Essentials will be effective May 1, 2026.

Once POET receives the new fee schedule and completes its review, OPT-IN / OPT-OUT packets will be sent to physician offices for participation decisions.

Please watch for additional communication once the review process is complete

UHC Community Plan Policy Update Feb. 2026

For a comprehensive summary of the latest updates, refer to the Medical Policy Update Bulletin: February 2026

Medical Policy Updates:

Medical Benefit Drug Policy Updates:

What is an EPO

In health insurance, an EPO is an Exclusive Provider Organization plan.

Here’s what that means in practical terms:

What an EPO plan is

You must use doctors, hospitals, and facilities in the plan’s network
👉 Except for true emergencies
You do not need a referral to see a specialist
Care received outside the network is not covered at all (again, except emergencies)

Pros of an EPO

Usually lower monthly premiums than PPO plans
No primary care referral requirement
Simpler than HMO plans

Cons of an EPO

No out-of-network coverage
Limited flexibility if you travel a lot or want a specific doctor who isn’t in-network

How EPO compares to other plans

EPO vs PPO: PPO allows out-of-network care (at higher cost); EPO does not
EPO vs HMO: HMO usually requires referrals; EPO does not

Disclaimer: The information provided in this blog is for general educational purposes only. While Ink strives to explain insurance concepts accurately and clearly, payer rules, contracts, and policies can vary widely by plan, state, and provider agreement—and they change frequently.

This content should not be interpreted as definitive guidance or a substitute for reviewing payer manuals, contracts, or official communications. Physician offices are encouraged to conduct their own research and verify requirements directly with the applicable insurance carriers before making operational or billing decisions.

HealthSpring Provider Manual 2026

Have you received your copy of the HealthSpring Provider Manual?

Employer Group PPO/EPO Hybrid

Interpreting insurance cards has never been easy, but with the constant changes in today’s insurance landscape, it has become nearly impossible.

Every week seems to bring a new insurance company—or an established insurer that has acquired several others, rebranded, and rewritten the rules.

On top of that, there are hybrid plans like POS and EPO, along with discount cards, medical cost-sharing programs, limited-benefit plans, and the growing model of Direct Primary Care.

The one pictured below is an ultimate example!

It takes hybrid to a new level of complexity.

By mixing the rules of PPO and EPO in one plan.

Therefore, I, Sir Seymore, have taken my red pen in hand in an effort to make sense of it all.

Feel free to download this card for your records.

CLIA-Checks No Longer Accepted

Per CMS CLIA Communications Update: This is your last chance to go paperless before we eliminate paper fee coupons and CLIA Certificates on March 1, 2026. In addition, laboratories must pay their CLIA certification and survey fees online (checks will no longer be accepted). Failure to go paperless may result in billing or certification issues.

When you switch to paperless, your laboratory will get:
• Email notifications from CMS
• Electronic fee coupons*
• Electronic CLIA certificate – no more waiting for it to come in the mail*
*This does not apply to CLIA-exempt states or state licensure.

To switch, you must either:
• Email your State Agency
Tip: Include your laboratory name, laboratory director or owner’s name, CLIA number, director or designee’s signature to help your State Agency make the switch.

• Contact your Accreditation Organization (for accredited labs).
They can add or update email addresses for the laboratories they survey.

Reach out to your State Agency or Accreditation Organization for assistance. For more details, visit Clinical Laboratory Improvement Amendments (CLIA).

HealthSpring patients in Polk County should go to Quest or LabCorp.

ERISA Plan vs. Third-Party Administrator (TPA)