Self-Funding 101: How Does Self-Funded Health Insurance Work?

Highlights  

• Knowing how self-funded health insurance works is essential to selecting and implementing a self-funded employee benefits plan.

• For small to midsize businesses, self-insurance offers a more affordable alternative to traditional fully insured or level-funded plans.

• When you self-insure as part of a group medical captive, your organization can benefit from the savings and advantages of self-funding, like transparency, flexibility, and control, while minimizing risk and volatility.

Knowing how self-funded health insurance works is essential if you are considering moving from fully insured to self-insurance for your employee benefits plan. With self-funding, employers assume the financial responsibility of providing healthcare benefits to employees, allowing for more flexibility, data insight, and control than traditional fully insured plans.

Making the switch to self-funding means designing your healthcare plan to suit your organization’s needs. You can custom design the plan to best suit the unique needs and interests of your employees.

Based on Part 1 of our “Three Easy Pieces” webinar series, this post lays the foundation for self-funding. We will summarize key discussion points from the webinar to  help you understand how self-funded health insurance works.

I had the pleasure of moderating the discussion with insights from our guest speakers, Kenny Fritz and Tim Ott, Senior Regional practice leaders at Roundstone.

The Current Healthcare Landscape

Employers across the U.S. are grappling with the challenge of rising healthcare costs and the impact on employee satisfaction. Healthcare has become a top business expense, second only to payroll, and costs continue to escalate. Businesses with employer-sponsored healthcare plans have experienced consecutive double-digit premium increases of 20% and 43% over the last 5 and 10 years, respectively.

To manage these escalating expenses, employers are often forced to shift the financial burden onto employees through higher co-pays and deductibles. However, this cost-shifting approach can cause employee dissatisfaction, leading to quiet quitting, high turnover, or inability to attract quality talent. The escalating cost of healthcare has a significant impact on employee retention and hiring, placing HR leaders under tremendous pressure.

In a video discussing a recent Journal of American Medical Association article, healthcare expert Dr. Eric Bricker explains why there has been a 40% increase in employee healthcare contributions over the past decade. Today, the average household spends $5,600 per year on health insurance, surpassing the $4,600 spent on food.

These findings underscore the unsustainable nature of the current healthcare system and emphasize the crucial need for alternative funding solutions to address these pressing issues. America’s healthcare crisis has become an overwhelming burden for families — and employers are caught in the middle.

Exploring Alternatives: Self-Funding and Group Medical Captives

When looking for an alternative to traditional fully insured or level-funded plans, working with your benefits advisor is crucial. Your advisor can help you understand various self-funding and alternative options and select the right plan that meets your business’  financial and healthcare coverage needs.

Alternative healthcare plan options include association plans, pure self-funding, reference-based pricing, and self-funding in a group medical captive. These alternative funding approaches provide flexibility, data insight, control, and potential cost savings compared to conventional models.

• Some associations offer health plans for their members and their employees.They can be either self-insured or fully insured. They enable employers to join together, accessing larger risk pools and potentially obtaining better rates. If you are a member of an industry association, it would be worthwhile to explore their options.

• Pure self-funding grants employers greater control over healthcare plans and claim costs, but there is little protection from volatility or risk, which is why this approach is typically reserved for larger companies.

• Reference-based pricing (RBP) involves setting limits on reimbursement for specific procedures. It is a cost containment strategy employed by some health plans where reimbursement rates for medical treatments are based on a specific reference point — often a set percentage above Medicare — rather than on a provider’s billed charge. The main drawback is that RBP may significantly limit provider networks, thereby making it harder for members to access the care they need.

• Self-insurance in a group medical captive pools together hundreds of companies to share costs. Compared to pure self-funding, the captive adds a layer to absorb risk and volatility and allows participating companies to share in any underwriting profits, instead of their unused healthcare spend being pocketed by the insurance company. This means the captive actually returns any unspent premium to all captive participants annually pro rata.

Self-Funding for Small to Midsize Businesses

With pure self-funding, there are a few risks and limitations for small to midsize companies to consider. While this strategy can offer control over healthcare plans and cost savings, it may pose financial risks for smaller employers with limited resources. That’s why self-funding has traditionally been reserved for Fortune 500s that employ at least 1,000 employees.

An innovative solution to this issue for smaller employers is the group medical captive. Self-insurance in a group medical captive provides midsized employers with the benefits of self-funding while mitigating the risks. Joining a captive allows similar-sized employers to pool their resources and share risk with other companies, gaining access to competitive rates and more stable premium costs. They essentially gain the risk predictability of the Fortune 500s, even if they only have 25 employees.

Self-insurance under a group medical captive presents a viable option for mid-market employers seeking greater control and cost effectiveness in managing their healthcare benefits.

How Does Self-Funded Health Insurance Work Under a Group Medical Captive?

So, how does a group medical captive work as a self-funded model? A self-insured group captive operates through three funding buckets: claims, risk-sharing pool, and reinsurance. Claims are funded by employer contributions, while the risk-sharing pool allows participants to share the financial burden of high-cost claims collectively.

Reinsurance, or stop-loss insurance, provides additional protection against catastrophic claims. A key advantage of the self-insured group captive model is shared risk. Participants benefit from more stable premium costs and reduced volatility by pooling resources and spreading the risk across multiple employers.

The self-funded captive arrangement offers flexibility and customization of benefits, allowing employers to tailor plans to meet the unique needs of their workforce.

Even better, joining a captive does not require additional administrative work for employers. Instead, when you self-insure under a group medical captive, you receive administrative support and guidance from the stop-loss reinsurance captive (Roundstone) and your chosen Third-Party Administrator (TPA) and pharmacy benefit manager (PBM). A self-funded plan in a captive is streamlined and easy to manage. For employees, there’s no noticeable change — just a great experience and appreciation of great benefits.

The Substantial Cost Savings of  a Self-Insured Group Medical Captive

Self-insured group medical captives provide multiple cost savings opportunities over fully insured and level-funded options. The group captive model offers three avenues for cost savings: claims savings, a shared risk pool, and pharmacy rebates.

1. Employers only pay for the healthcare they use. All savings from the claims account stay with them. Captive participants can benefit from claims savings through proactive cost containment measures, claim error and fraud protection, and improved health plan utilization strategies.
2. Unused premiums from employers’ pooled captive funds are returned annually to employer clients on a pro rata basis. The risk-sharing pool in a self-insured group captive provides better predictability and stability in premium costs by spreading the costs across multiple employers. This means that even in a bad year, you can get money back from the captive.
3. Transparent and pass-through PBMs send 100% of rebates and pharmacy savings back to employers — a considerable savings. Roundstone only works with transparent and pass-through PBMs.

Learn More About How Self-Funded Health Insurance Works 

Want to watch this 30-minute webinar on demand and hear how self-funding works? 
Watch Self-Funding 101 now. 

Contact us today to get started with a health plan assessment and quote.