Fully Insured VS Self Funded

In a traditional fully insured health plan, your company pays a premium.  The premium rates are fixed for a year, and you pay a monthly premium based on the number of employees enrolled in the plan.  Your monthly premium only changes during the year if the number of enrolled employees in the plan changes.

The insurer collects the premiums and pays the health care claims based on the benefits in the policy you purchased.  The covered persons are responsible to pay any deductible amounts or co-payments required for covered services under the policy.

The cost of a self-funded plan has fixed components similar to an insurance premium, e.g., administration fees, stop-loss premium, and variable costs (the claims expense).  The administrative fees, stop-loss premiums, and any other set fees charged per employee are referred to as fixed costs and are billed monthly based on plan enrollment just like an insurance premium.  The employer sponsoring a self-funded plan also pays the claims costs incurred by the covered persons enrolled in the plan, and this cost varies from month to month based on health care use by the covered persons.  Stop-loss insurance reimbursements are made if the claims costs exceed the catastrophic claims levels in the policy.  So the total cost of a self-funded plan is the fixed costs plus the claims expense less any stop-loss reimbursements.

Capping Catastrophic Claim Risks

Even though these plans are called self-funded plans, an employer typically does not assume 100% of the risk for catastrophic claims.  Rather, the employer buys a form of insurance known as stop-loss or excess-loss insurance to reimburse the employer for claims that exceed a predetermined level.  This coverage can be purchased to cover catastrophic claims on one covered person (specific coverage) or to cover claims that significantly exceed the expected level for the group of covered persons (aggregate coverage).

Creating Your Self-funded Plan

The flexibility of self-funding helps employers use their health benefit plans the way they were originally intended – to attract and retain the finest employees in the industry. Benefits can be customized to meet your employee’s needs and to satisfy company objectives. EKA Brokerage will help you design your self-funded plan.

Not just for large employers

A common but mistaken impression is that self-funding is only for large employers.  In fact, self-funded health plans can be prudently set up by smaller employers as well.  When we set up a self-funded plan for a smaller employer, we help them select the appropriate level of stop-loss or excess-loss insurance, which provides reimbursement for large catastrophic claims.  Stop-loss insurance allows smaller employers to consider this very economical approach to providing employee health benefits because it protects them from large claims.


Please contact EKA Planning (516) 944-0200 to discuss options that may be available to you.