From ChamberChoice & Smart Business 

For business owners today, the continual rise in group health insurance premiums has put a strain on their employee benefits budget, forcing them to explore less traditional means of cost containment.

“Most have already raised deductibles and cost-sharing, implemented high deductible plans and tax advantaged savings accounts and increased employee cost sharing. As a result, many insurance companies and third-party administrators (TPAs) have answered by creating new ways for groups of almost all sizes to take advantage of funding alternatives as a way to potentially reduce their benefits cost,” says Domenic Pascucci, consultant at JRG Advisors.

Smart Business spoke with Pascucci about the funding options that may be beneficial for you to consider, whether you own a business with 25, 250 or 2,500 employees.

What has caused the growth of funding alternatives?

Not too long ago, only the largest groups would stray from a fully funded insurance program to one that they self-funded.

If a company had fewer than 1,000 employees back in the 1970s, they probably wouldn’t even think about self-funding their medical insurance plan. But since then, and especially in the past several years with the passage of the Affordable Care Act, many funding options have emerged. This allows nearly any business owner with more than 10 to 25 employees to transition to an alternative funding arrangement, based on their financial capabilities, benefit objectives, employee demographics and utilization history.

What are these options and how do they work?

Group medical plan funding, in general, can either be fully insured or self-insured. A fully insured program provides insurance with the least amount of risk to the employer. With a fully insured program, the insurance company evaluates the risk and sets a premium level. The customer is not expected to pay the difference to make the carrier whole if its claims utilization is more than the carrier expected or get any refund of premiums paid if the claims utilization is less than expected.

At the other side of the risk spectrum are self-insured programs. A self-funded health care program is one where an employer assumes the financial risk for providing health care benefits to its employees. Conceptually, the employer utilizes a TPA and establishes a ‘bank account’ to pay each claim from its own funds as they are incurred. Other than paying the TPA a fee for its role in administering the claims adjudication, providing utilization reviews and for ‘renting’ the TPA’s negotiated discounts with a particular carrier, the employer’s risk is directly tied to the claims experience of the employees and their dependents. Large, unexpected ‘shock’ claims adversely affect such consistency, and for this, a group usually obtains stop-loss protection, limiting the impact of these large claims. The advantage of self-funding is more control over plan design, improved cash flow and the avoidance of certain taxes imposed on the employer.

In between fully insured and self-insured plans are level funding arrangements. Level funding is a variation of self-funding that addresses a chief concern for employers — the variability of cash flow from month to month that they might experience on a traditional self-funded arrangement. In level funding, the TPA’s underwriting department sets a fixed rate that the customer pays each month (along with any necessary administrative fees), greatly assisting the company in its budgeting effort since any monthly claim spikes are eliminated. Additionally, different insurance carriers and TPAs in different regions of the country have developed other variations of self-insured arrangements that may be appealing to individual businesses.

The decision to change funding to one of these arrangements should be evaluated carefully with assistance from an experienced benefits professional, as there are nuances among each variation that might work out to be an advantage or disadvantage for any particular customer. Although traditionally limited to larger groups, recent changes and safeguards have allowed groups with as few as 25 employees to consider self-insurance or one of its modified versions.