This means a company pays part of its own insurance losses and also assumes the role of an insurance company by establishing systems to pay claims. The company identifies certain loss exposures and then decides to become responsible for settling all or part of the claims arising from such risks. For an employee benefits plan, the employer legally establishes and then operates a plan. Payments are made based on a plan document. Reinsurance is purchased to protect the plan from higher than expected losses - not to directly protect individual participants (as they are protected by the plan and funded by the plan’s assets - but to protect the business.

Graded funding offers clients a self-funding experience with stop-loss protection. Clients pay for claims as they are incurred, so costs are aligned with claim flow patterns throughout the life of the plan. This type of funding is usually considered administrative services only as this is offered by the actual insurance carrier, and is not outsourced to an independent third-party administrator. This can be a good fit for those that understand self-funding, however prefer to keep 100% of unused claim dollars.

With Level Funding, the employer pays a fixed monthly amount to cover the costs of administration, stop loss, and claims funding. Level funding offers all of the benefits of traditional self-funding with the added benefit of stable monthly costs, so groups can reap the financial rewards of being self-insured. This funding method is ideal for employers with 25 or more health employees who have cultivated a culture of wellness and engagement. The employer usually shares with the carrier any excess in premiums vs. claims paid.

This is the typical structure where an employer purchases health coverage from an insurance carrier for a per-member premium. The insurance carrier assumes the risk that the employees will use their healthcare, and pays for that in accordance with their selected plans. This is like paying a cable bill every month. The bill is always the same and usually increases at renewal.

The most common type of captive and typically used for larger entities, a Single Parent Captive (SPC) or Pure Captive, insures the risks of related companies and is owned and controlled by the related company or its affiliates. A Single Parent Captive is a closely held insurance company whose insurance business is primarily supplied by and controlled by its owners, and in which the original insureds are the principal beneficiaries. The parent of the captive insurance company provides the capital in forming the captive, and has direct involvement and control over the captive’s major operations including underwriting, claims and investments. The SPC can choose its retention level, reinsurer, aggregate stop limit, service providers, and may write any line of business, including coverage and limits that aren’t available throughout the insurance marketplace, such as credit risk and terrorism. read more »read less »

A Group Captive is formed by a group of individuals or entities that come together to jointly own a captive insurance company. You can have a homogeneous Group Captive, which typically covers insureds in the same industry group; or a heterogeneous Group Captive, which allows a group of insureds from entirely different industry groups to own the captive jointly. Group Captives are typically for small to midsize businesses with premiums volumes not big enough to warrant owning or operating their own SPC. Members pool together resources to share their risks, as well as profits and losses. Since only businesses that are well run and safety focused qualify to join the Group Captive, the collective risk is much lower than in the general insurance pool. Group Captives typically cover Auto, Workers Comp and General Liability and require a minimum premium for each insured. The captive’s structure, retention level, aggregate stop limit, and service providers are all predetermined.

Association Captives are similar to Group Captives except that they are sponsored or owned by a group of entities within a particular organization with common insurance needs and similar exposures. read more »read less »

Protected Cell Captives (PCC) were created as way for smaller businesses to take advantage of a stand-alone captive without the expenses involved in forming one. Think of a PCC as a big, single piece of honeycomb with many hexes (cells) in it. A sponsoring entity sets up and owns the principal company (the honeycomb) and sells or rents the cells to businesses that need it. The financial arrangement includes working capital, surplus and licenses from the parent company, who also arranges the necessary administrative, claims, engineering, reinsurance placement and admitted fronting services. Under the protected cell structure, there is no pooling of risk between cells. Other benefits includes:

Risk Retention Groups are liability insurance companies owned by their members. They allow businesses with similar insurance needs to pool their risks and form an insurance company that they operate under state-regulated guidelines. RRGs are formed using a combination of state and federal laws under the auspices of the Federal Liability Risk Retention Act (LRRA). All insureds of an RRG must be owners of the RRG, and all owners of the RRG must be insured. RRGs may be formed under a state’s captive or traditional insurance laws. The RRG is domiciled in one state, but may do business in any other state by completing a registration process and designating the state’s commissioner as agent for service of process.

Let’s say that a participant needs a certain kind of surgery, and a hospital would expect to be paid $2,500 for the surgery even if some insurance carriers may have contracted to pay less than that. The Medicare rate is $500, and the reference-based pricing plan’s fixed limit is 200 percent of the Medicare price, which comes out to $1,000.

Provider reimbursement is based on a percentage of what Medicare would typically pay the provider, which often ranges from 120% to 170% of Medicare reimbursement. By comparison, hospitals utilizing the traditional PPO network are billing roughly 350% to 1,000%+ of Medicare reimbursement.

The TPA or repricer acts as a claim advocate and negotiates the claim with the particular facility/hospital.

Stop loss limits a self-funded employer’s health plan liability to a specified amount and protects the financial integrity of the self-funded plan The contract is between the carrier and the employer - it does not cover individuals.

Carve-out and carve-in plans are two options employers have for managing different medical benefits provided to their employees.

Carve-outs enable employers to contract with a separate company to “carve out” benefits that focus on a specific disease: like diabetes; or cancer and other specialty treatments; or a particular service, like pharmacy benefits.

Alternatively, a carve-in plan leaves all healthcare arrangements under one roof, controlled by a single medical provider. In the case of a pharmacy benefits plan that’s carved in, a company’s medical provider holds the PBM contract, handling the benefits and costs while the company remains one step removed. read more »read less »

A pharmacy carve-out is when an employer separates, or carves out, their prescription drug benefits from their major medical plan to contract directly with a PBM. Today, many companies, from large Fortune 500s to small and medium-sized businesses, are carving out pharmacy benefits, and for good reason. In contrast to a carve-in strategy, carve-out plans give employers better control over pharmacy benefit costs, a crucial consideration as the costs of prescription drugs continue to rise.

Carve-out plans give employers transparency into their pharmacy benefits, allowing them to have greater understanding and control of spending, negotiate better deals, and ensure the program is performing as promised. Contracting directly with a PBM gives employers direct access to the cost of their pharmacy benefits, and the data to evaluate program performance. read more »read less »

Prescription drug coverage is the single most utilized health care benefit — trending annually at 15 to 25 percent. With the cost of prescription drugs rising, the resulting increase in healthcare spending is impacting the bottom line. Carved-in employers often feel out of the loop as they can’t access accurate data about their pharmacy benefits spend.

Carve-out plans, however, can offer greater transparency and control, both critical components for helping employers and employees manage prescription drug costs. They also give employers direct access to PBMs who are knowledgeable about pharmacy benefits. With many high-priced prescription drugs, a carve-out plan allows companies to focus attention on managing pharmacy benefits costs separately from the rest of their medical plan. In addition, maintaining an effective pharmacy benefits plan keeps patients from shouldering too much of the cost of prescription drugs.

A carve-out plan can offer employers another strong solution for offering a complete pharmacy benefits program while also keeping spending in line. The first step is to work with your PBM to achieve the transparency and cost savings every employer needs. read more »read less »

Group life insurance is a type of life insurance in which a single contract covers an entire group of people. Typically, the policy owner is an employer or an entity such as a labor organization, and the policy covers the employees or members of the group. Term insurance is the most common form of group life insurance.

Long-term disability insurance helps ensure that employees will still receive a portion of their income when they are absent from work for an extended period due to a covered disability. These absences may be a result of accidents, injuries or illnesses that happened on or off the job.

An employee’s savings might not be enough if an illness, injury or pregnancy keeps them out of work beyond their paid sick days. Short-term disability insurance (STD) helps protect employee income during extended work absences and can help employees pay the bills when they cannot work due to a covered claim.

All employees can benefit from a regular eye exam to help keep their vision healthy. Our vision coverage is a cost-effective benefit solution that offers flexibility and choices for employers and employees.

Accident insurance can serve as a sensible way to help employees cover expenses that many medical plans may not. Accident insurance benefits are paid directly from the Insurance carrier to the covered employee – not to the doctors or the hospital. The money your employees receive can be used however they wish – for medical bills, childcare, mortgage payments, groceries, or any other expense, allowing them to concentrate on getting better instead of how they’re going to pay their bills.

Whether you’re in need of routine cleanings, braces, or a filling, a solid dental plan makes it easier for you to help protect your smile and your budget. Routine visits to the dentist help prevent costly dental bills later on, as well as problems linked to medical conditions like diabetes or heart disease. If you have a choice of plans, consider your oral health needs and ability to pay for unexpected major services, like a crown. If you have children, consider more comprehensive coverage for less out-of-pocket costs, as well as an option for braces.

Critical Illness Insurance (CI) provides a financial, lump-sum benefit to employees upon diagnosis of a covered illness. These covered illnesses are typically very severe and likely to render the affected person incapable of working. Because of the financial strain these illnesses can place on individuals and families, critical illness insurance is designed to help ill employees pay the mortgage, seek experimental treatment or handle unexpected medical expenses.

Health and accident insurance for an international trip. Groups of 5 or more people qualify for lower rates.

Health and accident insurance for frequent travelers. 

International health plans that cover you inside and outside the United States.

Worldwide health insurance and international health plans for students and faculty, captains and crew members and corporate expats and travelers.