Level-Funded Group Health Plans

What Are Level-Funded Group Health Insurance Plans?


Level-funded health plans, a subset of self-funded plans, are gaining traction as an alternative to traditional fully-insured health insurance. These plans combine the predictability of fixed monthly payments with the potential cost savings of self-funding, making them an attractive option for small to mid-sized businesses.


Employers pay a fixed monthly amount that covers three components:

 

  • Administrative Costs: Includes third-party administration (TPA), network access, and customer support
  • Claims Funding: Allocated for employee healthcare claims
  • Stop-Loss Insurance: Protects against catastrophic claims by capping the employer’s financial risk


If claims are lower than anticipated, employers may receive a refund of unused funds at the end of the coverage year. Conversely, if claims exceed the funded amount, the stop-loss insurance covers the overage, ensuring financial predictability.

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Benefits of Self-Funded Group Health Insurance Plans


There are a few different advantages to having a level-funded insurance plan: 


  • Avoidance of State Taxes: Since level-funded plans are governed by federal law under ERISA (Employee Retirement Income Security Act), employers can avoid state insurance premium taxes.
  • Claims Transparency: Employers gain access to anonymized claims data, enabling them to identify trends and implement cost-saving strategies.
  • Cost Predictability: Fixed monthly payments eliminate the uncertainty often associated with self-funded plans.
  • Flexibility: Employers can customize the benefits of a level-funded plan to suit their workforce’s needs.
  • Lower Costs: Level-funded plans often have lower premiums than fully-insured plans, especially for healthy employee groups.
  • Refund Potential: Employers may receive a refund if claims are lower than anticipated, providing an opportunity for savings.



What to Consider When Choosing a Level-Funded Group Health Insurance Plan


Despite their advantages, level-funded health plans have some elements that employers should carefully consider:


  • Administrative Complexity: Employers must manage additional administrative tasks when using a level-funded plan — most will partner with TPA for assistance.
  • Financial Risk: While stop-loss insurance mitigates catastrophic claims, employers are still responsible for regular claims up to the funded amount.
  • Limited Refunds: Not all surplus funds may be returned at the end of the coverage year — the refund is dependent on the plan’s terms.
  • Regulatory Requirements: Employers must ensure compliance with federal regulations, including reporting requirements under ERISA — partner with a knowledgeable insurance agency to help you navigate these requirements.
  • Unsuitability for High-Risk Groups: Businesses with high claims frequency may not see savings and could face higher costs.



For Whom Are Self-Funded Group Health Insurance Plans Best Suited?


Level-funded plans are best suited for:


  • Cost-Conscious Employers: Those who are seeking predictable costs with the potential for savings
  • Growth-Oriented Companies: Organizations that want the flexibility to scale benefits as they expand
  • Healthy Workforces: Employers with low healthcare utilization rates can maximize refund opportunities
  • Small to Mid-Sized Businesses: Companies with 10 - 200 employees looking for an alternative to fully-insured plans