Self-Insurance Guide
Consider a self-insured arrangement to gain control over your costs and design benefits that fit the needs of your people.
Here's a 7-step guide to start saving next plan year.
Step 1: Get Stop Loss (Catastrophic) Insurance
The most important part. Instead of 100% carrier risk, you pay each individual claim (office visit, lab, test) up to a "stop loss" amount, called the specific deductible. You decide the specific deductible based on employee count and risk tolerance.
An example for a 100 person company is a stop loss amount of $50,000. Larger companies may increase this number. You can also purchase aggregate stop loss which insures your entire group above an amount, called the "attachment point."
Step 2: Contract with a Third Party Administrator (TPA)
There's a wide range of non insurer third party administrators. They maintain member eligibility, adjudicate claims, pay claims from your account, and provide customer service.
Step 3: Design Your Benefits
The fun part! You get to decide the exact plan design based on your organization's budget, needs, culture and more. Deductibles, co-pays, co-insurance, and out-of-pocket maximums are the main variables.
You also get to decide what services are covered and which are excluded, as long as they comply with ACA rules.
Step 4: Select a Medical Network
Traditional insurers offer networks of contracted providers, like Cigna and United. There are also alternatives like First Choice. You pay an access fee (like $3 pepm) to use the selected network.
Step 5: Select a Pharmacy Benefits Administrator (PBM)
A key area for savings. Switching from a traditional PBM to one that is cost plus often saves 15-30% off prescription drug spending.
Step 6: Insert Innovation and Special Programs into Plan Design
AI health services, virtual visits, and Direct Primary Care can all be integrated into your plan.
Then- consider the needs of your employee population. Specialized programs for fertility, musculoskeletal, and diabetes management are all available to you- they're not commonly included in traditional fully insured carrier arrangements.
Step 7: Contract Required Add-Ons
A few things that must be included are medical director services (for claim disputes or ambiguity), pre-authorizations for surgeries and high ticket items, and COBRA administration.
