Self-Funding Solutions for Employee Health Benefits
60%
of US employers self-fund their health benefits.
What is Self-Funding? A Self Funded, or Self-Insured plan, is a health benefit plan in which the employer assumes the financial risk for providing healthcare benefits to its employees. Self-Insured employers pay for claims out-of-pocket as they are presented instead of paying a pre-determined premium to an insurance carrier as in a Fully Insured plan. Typically, a self-insured employer will set up a special trust fund to earmark money (corporate and employ-
The cost of providing a fully-insured plan will
ee contributions) to pay incurred claims. A Third Party Administrator (TPA) is selected by the employer to provide administrative support and ongo-
continue to increase due to new
ing guidance. Through proper plan design and administration, self-funded
expenses, expanded risks and
employers are able to:
additional covered claims brought on by PPACA.
Pay Only for Actual Claims Avoid paying for insurance carrier profit margins, administrative fees, risk charges, premium taxes and contingency margins.
Governed solely by ERISA, self-funded plans are exempt from many costly PPACA and state mandates including premium
Avoid Costly Healthcare Reform Mandates PPACA requirements such as modified community rating, coverage of “essential health benefits”, limits on cost sharing and the health insurer fee will continue to inflate costs.
taxes, modified community
Cash Flow Benefit
ratings, coverage of “essential
Funds held by the insurance carrier in the form of reserves for
health benefits”, limits on cost
unreported and pending claims, are freed for use by the employer.
sharing and health insurer fees.
Control of Plan Design Complete flexibility in determining the appropriate plan design and the By purchasing stop-loss
ability to redesign the plan at any time.
insurance, employers do not assume 100% of the risk
Mandatory Benefits Are Optional
for their health plan. Instead,
State regulations mandating costly benefits are optional because self-
stop-loss insurance will reimburse
funding is regulated by federal legislation only (ERISA).
the employer for expenses that exceed a predetermined level.
Better Cost Reporting Frequently updated claims reports and predictive modeling provide actionable data for better optimization of your benefit plan.
How Does Self-Funding Work?
The flexibility to self-
• Employers design their health benefits plan to mirror fully insured benefit models or adapt their plan to meet specific needs through a customized suite of options. • Stop-loss insurance is arranged to limit the employer’s loss and ensure that catastrophic claims do not upset the financial integrity of the self-funded plan. The amount of risk to be reinsured is determined by
funding allows your organization to use a health benefit plan as it was originally intended- to attract and retain the finest employees.
the employer’s size, nature of business, financials and risk tolerance.
PayerFusion provides comprehensive support and specialized expertise. PayerFusion develops customized self-funded solutions to meet the needs
A fully insured plan’s fixed premium is like paying for cable. It doesn’t
of employers and their health plan members. Our all-inclusive services
matter how many hours you
are designed to provide sustainable cost control, efficient administration
watch, you pay the same bill
and a variety of benefit options for employers. We provide administration
each month.
and guidance for every aspect of your self-funded plan. • Premium Collection and Administration
A self-funded plan
• ID Card Design and Distribution • Benefit Design and Support
works more like your electric bill. There will be costs,
• Claims Management/Processing
but some are controllable, like
• Case Management
how efficiently you use lights or
• Stop-loss insurance through pre-approved carriers
A/C.
• Cobra Administration • Access to a variety Provider Networks • Predictive Modeling and Benchmark Reporting
5200 Blue Lagoon Dr Suite 100 Miami, FL 33126 1.866.752.8881 info@payerfusion.com www.payerfusion.com