Learn the Basics: Group Health Insurance Plans

Raffa Financial ServicesRaffa Financial Services on 10/07/2021

When it comes to health insurance, people want the right amount of coverage. They also want coverage for what they see as high value (doctor’s visits, medical procedures, etc.). There are many insurance plans out there—the traditional fully insured plan, the level-funded plan, the self-funded plan…and you may be wondering what the difference is between them, and where to begin.

Where to start: fully insured plans


Fully insured plans are probably what come to mind when you think of group health insurance plans. Employers get the plan from an insurance company (carrier) and pay a premium to the insurance company. The yearly premium rates depend on how many employees are enrolled in the plan. When employees make a claim, the insurance company writes a check to the healthcare provider (hospital, doctor, etc.). Employees are responsible for paying the deductibles and co-pays defined in the plan.

A fully insured plan usually includes coverage for medical procedures, prescriptions, and doctor’s visits. Employers tend to go the route of fully insured for their business if they want to give their employees predictable benefits that remain consistent over time and provide the business with a regular monthly fee to manage cash flow.

The next step: level-funded plans


Level-funded plans are the go-betweens, the bridge between a fully insured plan and a self-funded plan (which we’ll discuss in a minute).

With level-funded plans, employers pay a set amount of money each month to the insurance company that funds a reserve account for claims and manages administrative costs and fees. Rates for a level-funded plan are defined by the number of employees and the estimated cost of anticipated claims. If the employer has a surplus of claims funds at the end of the year, they will receive a refund. If the claims are higher than estimated, they will receive a premium increase for any stop-loss coverage an employer has.

Employers usually choose level-funded plans if they anticipate employees not making many insurance claims and want to offer their employees insurance at an affordable cost. It also allows ease of access to utilization trends that show where employees might be overspending and allows employers to use education and wellness programs to improve claims costs.

Understanding self-funded plans

 
The popularity of self-funded plans is on the rise. A report published in 2020 found that 60% of workers in companies with three or more employees were on some kind of self-funded plan. But how does it work, exactly?

With self-funded plans, or self-insured plans, an insurance company provides administrative services. Like with level-funded plans, there is a fixed cost for administrative fees. But unlike level-funded plans, employers assume all the costs and financial risks in a self-funded plan. They pay for employee health claims from a bank account or trust fund set up for that purpose.

These plans have the highest amount of risk; however, employers can have stop-loss insurance that reimburses them for claims that exceed a predetermined level. There are two types of stop-loss insurance:

  • Specific stop-loss coverage, or individual stop-loss coverage, provides protection for employers against a high claim for any one employee. For example, if employers want a maximum liability of $150,000 per person, and an employee makes $200,000 in medical claims, specific stop-loss reimburses the employer for the $50,000 in excess claims.
  • Aggregate stop-loss coverage provides a set coverage ceiling on the amount of eligible expenses employers pay during that contract period. In other words, this is the coverage for all the employees total, not just for any one specific employee.

While self-funded plans can be expensive without stop-loss coverage, many employers find self-funded plans attractive. If they don’t need to pay fixed monthly premiums and they want to proactively manage claims costs with a hands-on approach, such as steering employees to high-value, low-cost providers and taking advantage of clinical wellness programs, self-funding may be a good fit.

Find the option that’s right for you

 
What’s right for one company may not be right for you. There are many different health insurance plans and different plan options, and taking a route doesn’t mean you take the route alone. Many advisors are well-educated in level-funding and self-funding.

Start a conversation with your broker to find what options may be right for your business. It’s also crucial do your research so you can fully participate in the conversations to determine what is the best for you and your employees.

 

Tired of working with insurance salespeople who only think one year at a time? Wonder what it would be like to have a broker who looks beyond your annual policy? At Raffa Financial, we’ll provide a corporate employee benefits strategy to help you achieve your long-term vision. Get in touch to find out how. 

Photo by julief514

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