preloader

FAQ

An Employer & Employee Friendly Platform

Our experience in all aspects of healthcare provider-based services allows us to design and develop a platform that is both employer and employee-friendly while allowing us to continuously provide you with the analytics necessary to help you make smarter decisions about your business and how to operate it most cost-effectively. First, it’s important to understand the competitive landscape of health benefits. At its most basic, the marketplace for health benefits consists of three offerings: But what’s really the difference?

Fully Insured Health Plans

Traditionally, when people talked about insurance, it was “Fully Insured”. The employer or its employee pays a premium to the insurance company in return for paying future “covered” medical claims that are beyond the “out of pocket” maximum (the amount that employees and their families will pay for that service). The totality of risk for the medical claims is borne by the insurance company. As insurance is a for-profit industry, the insurance company must cover its risk and make money. As the cost of medical care increases, so too do the premiums. In fact, according to the latest Kaiser Family Foundation Report, average annual employee contributions to premiums and total premiums for single coverage have risen nearly 22% over the past 5 years.

Self-Funded Health Plans

On the other end of the offering spectrum from traditional insurance are self-insured plans. These health benefits plans are created by and for the employers that fund them. In most instances, an employer will then hire professional actuaries, a plan administrator (a third party administrator) to manage the plan and contract with a reinsurance (or Stop-Loss) carrier to cover claims above a certain cost. This Stop-Loss insurance comes at a premium for the employer. In almost all instances, small businesses (those with less than 499 employees) find it difficult to predict with any accuracy.

Level-Funded Health Plans

Over the past 15 years, a middle ground between “self-funded” plans and “traditional” insurance has emerged. These “level-funded” health plans are a fairly simple type of self-funding that are designed for small businesses. Plan providers (such as American Trustee, Inc.) establish a Third Party Administrator and get approved by a stop-loss carrier who agrees to cover claims above a certain amount. As these plans don’t need to be rated at a community level (as is the case with traditional insurance), level-funded health plans generally cost less and minimize the risk to employers, but only if the TPA knows how to balance cost-control with excellent healthcare and customer service.