If you are a business owner, you know that insurance is important. But what type of insurance should you have? One option to consider is a self-insured program. This program has many benefits, so more and more businesses are choosing it.
This blog post will discuss what a self-insured program is, how it is regulated, how it can benefit your business and the pros and cons of choosing this type of health and benefits coverage.
What’s A Self-Insurance Program?
A self-insurance program is insurance coverage funded by the business rather than an insurance company. With this type of coverage, businesses set aside money to cover any potential claims.
How Does It Work?
Self-insured businesses are responsible for funding their claims. This means that they will need to have enough money to cover any potential claims. To do this, businesses will often create a reserve fund. This is a fund used to pay for any claims that may come up.
The amount of money set aside will depend on the size of the business and the amount of risk it faces. Businesses will also need to purchase stop-loss insurance. This type of insurance protects the business from any large claims that may come up.
The Difference Between Self-Insured And Fully Insured Coverage
A self-insured business pays for its losses, while a fully insured business purchases insurance from an insurer. There are advantages and disadvantages to each type of coverage.
The main advantage of a self-insured program is that the business has more control over its destiny. The insurer decides how much coverage the business needs and how much it will pay for claims with a fully insured program. The business has no say in the matter.
How Is It Regulated?
There are two main types of self-insured programs: fully insured and partially insured. Fully insured programs are regulated by the state in which they are offered. Partially insured programs are not regulated by the state and are only required to follow federal guidelines.
Regulations That Apply to Self-Insured Plans
Several key regulations apply to self-insured plans. They include:
- The plan must have a written document that sets forth the plan’s rules.
- The plan must spell out who is eligible for coverage and what benefits are available.
- The plan must have a claims procedure that is fair and equitable.
- The plan must have an appeals process for denied claims.
Regulations That Don’t Apply to Self-Insured Plans
Several regulations don’t apply to self-insured plans. Such as:
- The plan is not subject to state insurance laws.
- Self-insured plans do not have to cover the ACA’s essential health benefits, as the law does not require them.
- The plan is not required to pay state premium taxes.
- Self-insured plans are not subject to health insurance regulations like the Medical Loss Ratio rules.
What Are The Benefits?
There are many benefits of having a self-insured health plan for your business. Some of these benefits include:
You Only Pay For The Claims That Are Made Against Your Business: One advantage of being in a self-insured program is that you only have to pay for the claims made against your business. However, with traditional insurance policies, businesses have to pay a premium, regardless of whether or not any claims are made.
You Can Tailor Your Coverage To Meet Your Specific Needs: Another advantage of a self-insured program is that you can tailor your coverage to meet your specific needs. This means that you can choose the coverage you want and need without paying for coverage that you don’t need.
You Have More Control Over The Claims Process: With a self-insured program, you have more control over the claims process. This means that you can resolve issues directly with the provider without going through an insurance company.
You Save On Premiums: With a self-funded program, employers pay only for the claims incurred, plus administrative costs. This is usually much lower than the cost of premiums for a fully insured program.
What Are The Pros And Cons?
There are both pros and cons to choosing a self-insured program. It’s important to be aware of them before deciding whether this type of health and benefits program is a good fit for you.
Pros Of A Self-Insured Program
There are several advantages to choosing a self-insured program. One of the biggest advantages is that it can save you money. When you are part of a self-insured program, you only have to pay for the claims made against your business. This is different from traditional insurance policies, where you have to pay premiums regardless of whether you make a claim.
Flexibility:
Another advantage of self-insured programs is that they are more flexible. With traditional insurance policies, you are usually stuck with the coverage you choose when you first sign up. But with a self-insured program, you can adjust your coverage as your needs change.
Control:
Finally, self-insured programs give you more control over the claims process. When you make a claim, you will work directly with the provider to resolve the issue. This means that you can get the help and support you need without going through an insurance company.
Cons Of A Self-Insured Program
There are also some disadvantages to choosing a self-insured program. One of the biggest disadvantages is that you are responsible for all of the claims made against your business. This means that if you have many claims, your costs can increase.
Limited Availability:
Another disadvantage is that self-insured programs are not always available in all states. Each state has different regulations about self-insured programs, so you will need to check with your state to see if this program is an option for you.
Limited Eligibility:
Finally, some businesses might not be eligible for a self-insured program. To be eligible, businesses usually need to have certain assets and revenue. If your business does not meet these requirements, you will not be able to participate in a self-insured program.
Types of Self-Insured Programs
There are two main types of self-insured programs: fully insured and partially insured.
Partially Insured
Under a partially insured program, the business pays for some of the claims made against it. The amount that the business has to pay will depend on the policy.
Fully Insured
A fully insured program is when the business pays for all claims made against it. This type of program is more expensive, but it offers more protection for the business.
Self-Insured Vs. Traditional Insurance
Now that you know what a self-insured program is and how it works, you might be wondering how it compares to traditional insurance policies. Here are some of the key differences between these two types of coverage:
Cost: One of the biggest differences between self-insured programs and traditional insurance policies is the cost. Self-insured programs can be more expensive, but they also have the potential to save you money.
Coverage: Another difference between these two types of coverage is the amount of coverage. You can tailor your coverage to meet your specific needs with a self-insured program. But with traditional insurance policies, you are usually stuck with the coverage you choose when you first sign up.
Claims Process: The claims process is also different for these two types of coverage. With a self-insured program, you will work directly with the provider to resolve the issue. But with traditional insurance policies, you will have to go through an insurance company.
Is Self-Insured Coverage Common?
Yes, it is. Most large businesses are self-insured. The federal government and many state governments are also self-insured.
What Is A TPA (Third-Party Administration)?
A TPA is an organization that manages a self-insured program on behalf of the employer. The TPA may be responsible for claims administration, stop-loss insurance, provider networks, and other aspects of the program.
TPAs are regulated by state law and must be licensed by the state in which they operate. TPAs are required to maintain certain levels of financial stability and must follow laws and regulations related to handling claims and other program functions.
Advantages Of Using A TPA
There are many advantages to using a TPA for a self-insured program. These include:
- Providing expertise and knowledge in the design and administration of the self-insured program.
- Providing economies of scale in purchasing stop-loss insurance and other program services.
- Negotiating favorable rates with providers for services rendered to plan participants.
- Helping control costs by monitoring claims activity and working with providers to resolve issues that may result in unnecessary or excessive charges.
- Providing valuable data and information that can be used to improve the overall effectiveness of the self-insured program.
Some employers may choose to self-insure their health benefits plan because it gives them more control over their health care costs. Others may do so because they feel it gives them more control over the quality of care their employees receive. Still, others may choose to self-insure because they cannot obtain affordable health insurance coverage in the traditional insurance market.
How Nesso Benefits Can Help
Now that you know more about self-insurance programs, it’s important to understand how we at Nesso Benefits can help you. We understand that health benefits are an important part of your total rewards package. So our staff is dedicated to understanding what you need and developing unique solutions.
Our Nesso Group professionals have a customer-focused approach, taking on the administrative work and interacting with workers directly to lighten the responsibilities of businesses. Don’t hesitate to reach out now to learn more about how we can help and the different health benefits we provide.
