Premium Payment

The insurance company provides Fully Insured plans, where you the employer pay all or at least the required portion of the premium on behalf of your employees. Employers can ask their employees to pay a portion of their healthcare premium as well. The required employer premium percentage may vary between insurance companies.

With Fully Insured plans you can also offer to pay some of the premium for your employee’s dependents, but you are not required to. Some employers will offer Employee Only plans. These plans are a good choice when you have a work force where more spouses are getting greater health benefits from individual plans purchased with tax credits in the Federal Marketplace. Tax credits are not available if spouses are offered a group health plan. 

Deductibles, Co-Pays and Co-Insurance

Fully Insured plans will offer a variety of options in deductibles, co-pays and co-insurance levels. Some plans will offer more than one plan design to choose from. The amount of plan designs may depend on the number of enrolling employees.

Out-of-Pocket Maximums

Each plan design will have an out of pocket maximum both at the individual and family level. When that amount has been met the insurance company pays 100% until the plan deductible resets which can be at renewal or January 1.

This plan comes out of the Self-Funded industry. A Level Self-Funded plan has a premium just like a Fully Insured plan. However, in a Level Self-Funded plan there is a possibility to get a return of premium if the group claim loss is less than what is predicted.

These plans have lots of algorithms but the key point to remember is that you have the possibility of getting premium dollars back, which is not the case in a Fully Insured plan. A Level Self-Funded plan has a stop loss feature to protect the employer in case of a large loss claim. With a stop loss protection an employer can still be eligible for a return of premium even when a large claim was filed.

In addition, if the employer wants to move back to a Fully Insured plan there is a seamless transition, unlike in years past where some Self-Funded plans were burdened with run off claims for months.

This plan structure is not right for every employer but the sophistication of how these plans are priced and operate make them very competitive and worthy of consideration to employers who have a medium sized business.