Health insurance benefits are expensive. The rising costs of health care has driven up insurance premiums to levels where many businesses have been forced to reduce these benefits or drop them altogether. There is, however another option that is less regulated, taxed less and typically results in cost savings: self funded health insurance. The problem is, it's not always the best option for all employers, particularly the smaller ones. And there's a number of reasons for this:
What is self funded health care a.k.a. self-insurance?
Self-insurance is a method of providing health care to employees by taking on the financial liabilities of the care instead of paying premiums to an insurance agency to do the same. In other words: when a person covered under a self-funded plan needs medical care, the company is financially responsible for paying the medical bill (minus deductibles). It's an alternative risk transfer strategy that assumes the risk and liability of medical bills for those covered instead of outsourcing it to a third party. It's a surprisingly common practice:
Most (but not all) self-insurance plans are administered by a third party, usually a health insurance company, in order to process claims. The bills are simply paid for by the employer. Health insurance companies act as a third party administrators in what are called ASO contracts (Administrative Services Only)
Another common component of self insurance plans is stop-loss insurance. This is a separate insurance plan that the employer can purchase to reduce the overall liability of claims. With this type of insurance, if claims exceed a certain dollar amount, stop-loss kicks in paying the rest. There are two kinds of stop-loss insurance:
Specific – covers the excess costs from larger claims made by individuals in the group
Aggregate – kicks in when total claims by the group exceed a set amount
For example, a company who self-insures their $1000 employees projects $100,000 in medical care claims for the year. If they purchase aggregate stop-loss insurance for claims that exceed 120% of the expected amount or $120,000, the insurance will pick up the bill for the remaining claims. If the company purchases specific stop-loss insurance at 200%, if any single claim exceeds $2,000, the stop-loss pays the remainder.
Typically, self-funded insurance providers will purchase both specific and aggregate stop-loss insurance unless the conditions are such that specific stop-loss provides enough financial protection.
Benefits of self-insurance
There are a number of financial and administrative advantages to using self-funded health insurance plans for employers. According to the Self-Insurance Institute of America (SIIA) these include:
- The employer can customize the plan to meet the specific health care needs of its workforce, as opposed to purchasing a 'one-size-fits-all' insurance policy.
- The employer maintains control over the health plan reserves, enabling maximization of interest income – income that would be otherwise generated by an insurance carrier through the investment of premium dollars.
- The employer does not have to pre-pay for coverage, thereby providing for improved cash flow.
- The employer is not subject to conflicting state health insurance regulations/benefit mandates, as self-insured health plans are regulated under federal law (ERISA).
- The employer is not subject to state health insurance premium taxes, which are generally 2-3 percent of the premium's dollar value.
- The employer is free to contract with the providers or provider network best suited to meet the health care needs of its employees.
There are, however, some drawbacks to self-insurance policies:
- Health care can be costly, so heavy claims years can be extremely expensive
- Self insurance isn't tax deductible the same way the costs of providing health insurance is.
- Financial benefits are long-term, particularly with an investment component.
Small businesses at a disadvantage
Self insurance is much more prevalent for larger companies mostly because it is easier to predict health care costs from a larger group. The more people in the group, the less potentially damaging a single expensive claim will be to the plan overall. That's why less than 10% of companies with less than 50 employees use self-insurance. The graphic to the right [source: businessweek.com] gives a telling breakdown of its prevalence based on company size.
Because risk is more difficult to predict with smaller groups, stop-loss insurance is also more expensive for smaller businesses. The practice of “lasering”, or increasing deductibles for specific higher risk employees can also be much tougher on small firms. As a result, self-insurance tends to be a less cost effective option than it is for larger companies.
Another roadblock for small businesses is a lack of cash-flow that is necessary to finance self-insurance. This doesn't mean, however, that small businesses can't benefit from a self-insurance plan. In fact, an increasing number of small businesses still are. But fully understanding the risks and rewards for doing so can sometimes be difficult.
Because the only 3rd party administration of insurance (stop-loss) is between the employer and the insurance company directly, it is not subject to state level regulation the way traditional insurance policies are. Instead, they're regulated by the department of labor under the Employee Retirement Income Security Act – ERISA. Benefit administrators must still comply with federal standards despite the lack of state regulation.
California SB 1431
California is considering a proposed legislation to regulate the sale of stop-loss policies to smaller businesses. On the surface, the regulation looks as though it is an attempt to prevent small businesses from taking on too much risk. But the true intentions of the legislation may be to prevent cherry-picking of generally healthier small businesses (effectively removing them from the health insurance pool). This cherry-picking would theoretically cause traditional insurance premiums to become more expensive.
According to the SIIA, SB 1431 would prohibit the sale of stop-loss policies to employers with fewer than 50 employees that does any of the following:
Contains a specific attachment point that is lower than $95,000;
Contains an aggregate attachment point that is lower than the greater of one of the following:
$19,000 times the total number of covered employees and dependents;
120% of expected claims;
This legislation would effectively limit the options of small businesses as it would force them to purchase a more expensive low deductible stop-loss policies. And according to the SIIA, with this legislation, almost no small business under 50 employees would (nor should they) consider self-insurance as an option.
If the legislation is passed in California, it has been suggested that it is only time before other states follow suit and/or enact even stricter regulations on small businesses. The SIIA even has a facebook page dedicated to defeating the bill they say is:
“…unnecessary and will only exasperate the problem that small employers in California face in being able to afford the rising cost of providing quality health benefits to their employees.”
So while self insurance can be a relatively risky option for small businesses, with legislation like this, it could no longer be a realistic option at all… And, in effect: another competitive advantage big businesses will have over their smaller counterparts.