Self-Insured Health Plans
Self-insured (or self-funded) health plans are arrangements where employers, unions, and associations assume direct financial risk for employee health claims rather than paying premiums to an insurance carrier.
What is a Self-Insured Health Plan?
Employers pay claims as they occur, often using a Third-Party Administrator (TPA) to process them. These plans offer potential cost savings, greater customization, and tax advantages under ERISA, while typically using stop-loss insurance to mitigate high claim risks.
Key Features & Advantages
Cost Control & Savings
Employers only pay for claims incurred, saving on insurance company overhead and taxes, leading to potential savings of 24% on average.
Customization
Plans can be tailored to meet the specific needs of the company’s workforce, unlike “one-size- fits-all” fully insured policies.
Cash Flow & Transparency
Improved cash flow as funds are held until claims are paid. Employers receive detailed claims data to analyze spending.
Federal Regulation
Self-insured plans are regulated under federal law (ERISA) rather than diverse state insurance mandates.
Common Risks & Management
- Financial Risk: Employers are responsible for large claims.
- Stop-Loss Insurance: To manage risk, employers often purchase stop-loss coverage.
- Types of Protection:
- Specific Stop-Loss — Protects the plan against large individual claims.
- Aggregate Stop-Loss — Protects the plan if total claims exceed expected levels.
- Administration: Third-Party Administrators (TPAs) typically manage claims processing, provider networks, utilization review, and compliance reporting.
Self-Insured vs Fully Insured Plans
| Feature | Self-Insured Plan | Fully Insured Plan |
|---|---|---|
| Financial Risk | Employer | Insurance Carrier |
| Predictability | Variable | Fixed |
| Cash Flow | Pay claims as they occur | Fixed monthly premiums |
Who Self-Insured Plans Are For
- Employers
- Unions
- Professional Associations
- Multi-Employer Groups
Organizations considering self-insured health plans often seek greater control over healthcare costs, flexibility in plan design, and better transparency in claims data.
Pegasus Health Group works with employers, unions, and associations to explore strategies that balance cost control, risk management, and high-quality coverage.
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