Self-Funded 101

Your Plan. Your Choices. Your Savings.

HealthFirst specializes in creating and administering self-funded health insurance solutions for employers big and small. Self-funded plans offer most companies a way to save money on their benefits plans – while providing healthcare and customer service to employees that is just as good, or better, than they would receive in a traditional fully insured plan.

How does that work?

In a traditional fully insured plan, employers pay one set premium to a traditional insurance carrier. The premium covers administration costs and projected claims costs. The insurance company underwrites the risk: If your claims cost for the year is much higher than anticipated, the insurance company covers it, but you will receive a large rate increase the following year. But if your claims costs for the year are lower than anticipated, that extra money isn’t yours – it goes to the insurance company as profit. And, you still may receive a large rate increase the following year, depending on how the carrier’s pool of other plans fared.

In a self-funded plan, employers take on the risk – and the potential rewards – of providing health care benefits to their employees. If claims payments run much lower than projected, the extra funds in the claims fund are the employer’s to keep. And even if claims are higher than projected, the plan is structured to limit the employer’s potential loss.

That’s because of the unique design and benefits of self-funded plans. Here’s how it works:

Customized Plan:

Employer works with a consultant and/or a TPA to design a plan that serves its specific employee group. They choose their own levels of deductibles and co-pays, as well as other features and coverage they want; they don’t pay for those they don’t select.

Transparent Structure:

Costs are clearly outlined, so there are no surprises. The premium includes administration expense and stop loss coverage, which pays claims over a pre-determined ceiling, protecting the employer from large losses. Finally, the employer establishes an account to pay claims as they are incurred, allowing for better cash flow. They have full access to claims and utilization data, so they can see exactly how their money is being spent.

Managed Risk:

The risk to the employer is limited via stop loss insurance. The stop loss policy typically pays individual claims over a pre-determined ceiling and also includes an aggregate policy that pays total claims over a certain threshold. These amounts are set according to the group’s financial resources and willingness to take on risk.

Outsourced Admin:

Plan is typically run by a TPA, which processes and pays claims, provides customer service to employees, works with provider networks, and handles other tasks that would otherwise be performed by a carrier or the employer itself.

Tax And Regulation Advantages:

Self-insured plans are exempt from certain Affordable Care Act regulations. For instance, these plans do not have to pay premium taxes which can add 2 to 4 percent to total costs. Additionally, because self-funded plans are governed by the Employee Retirement Income and Security Act (ERISA), they aren’t subject to state coverage mandates. Employers can offer the same benefits to all employees, no matter where they live.

Self-Funded Health Plans

Control your benefits. With our self-funded plans, we help each group design and manage the plan that fits their employee population and their resources.


Employer groups with 100 or more employees are ideally suited to benefit from the advantages of self-funded insurance. The employee pool is large enough to distribute risk, and the potential cost savings are significant. Our self-funded solutions can be customized at every turn — to deliver cost-effective benefits and excellent care.

  1. Choose your plan design. Working with your broker or our account team, develop a plan that suits the unique characteristics of your employee team. Deductibles, out-of-pocket maximums, covered services, and employee contribution levels are among the factors that can vary.
  2. Choose your network. HealthFirst works with several provider networks  to give employees a broad choice of doctors and facilities.
  3. Determine your level of risk. Our analysts will help you determine your attachment point, the level at which your liability ends.
  4. Add additional benefits. Vision, dental, and other ancillary benefits can be part of your benefits solution.
  5. Monitor your coverage. Groups can monitor eligibility and utilization in real time through our portal, and will review their plan quarterly with their account management team. You’ll know exactly where and how your dollars are being spent.

Healthcare Highways Funding Advantage

This plan brings the benefits of self-funding to smaller groups of 2-100 employees – groups that typically do not qualify for a traditional self-funded plan or do not have the HR staff to administer one. With this plan, groups get the flexibility and savings of self-funded plans, plus the stable, predictable cost structure of a fully-insured plan. Similar to a traditional self-funded plan, if claims are lower than anticipated, the group gets to keep the savings.

In East Texas, Healthcare Highways Funding Advantage partners with the AccessDirect Platinum network to provide exceptional care at excellent prices.


Affordable Preventive Care

Simple Select is a self-funded preventive health plan that meets the minimum essential coverage requirements of the Affordable Care Act. Ideal for workforces that have not traditionally been offered health coverage, Simple Select provides a way for employers to offer affordable benefits, including free preventive care, while complying with new healthcare regulations.

Available for groups with more than 100 employees, Simple Select is a value-priced plan with many advantages:

  • Self-funded design; avoids taxes and regulations applied to fully insured products.
  • Provides preventive care required by the ACA, including common screenings for heart problems, diabetes and cancer; routine vaccinations; tobacco cessation programs and more.
  • Affordable. By carefully selecting benefits and services, while holding fees down, we’ve designed a plan that provides real value, but at a very competitive price. Simple Select allows employers to offer a useful benefit to employees, at a cost that’s far below the penalties that would be applied due to non-compliance with the ACA.
  • Customizable:
    • Level 1: Basic plan covers preventive care only.
    • Level 2: Provides a greater value than typical MEC plans, with up to four physician visits annually for each participant, at a low copay; generic drug plan with a $2 copay; and unlimited access to Teladoc telemedicine service.
    • Level 3: Adds additional benefits, such as emergency room care.

Administrative Services

We Make Health Plans Our Business. So You Can Concentrate On Yours.

Plan administration is all in the details.  When you choose an administrator to manage your healthcare benefits, you want a team who will take care of your staff – and your healthcare dollars – as if they were their own.

Our TPA team specializes in detail-oriented, personalized service.

  • Each group gets an account management team, who serves as your liaison to the team members who handle the day-to-day tasks that make a benefits plan run smoothly.
  • Our cutting-edge technology means you’ll always have access to the data and reports that show how your plan and your dollars are being utilized. 
  • Our team approach means you’ll always have someone who can answer your questions and resolve concerns.


Benefit Plan Design

Working closely with clients, consultants, and partners, we put together a plan that is tailor-made for each group, with varying levels for such factors as copays, deductibles, coinsurance, employee cost-sharing levels and covered services, and the additional products and services your group needs.


We perform all the behind-the-scenes work that keeps your plan running smoothly.

  • Enrollment, eligibility and ID cards: We do all the legwork to get members set up in the plan, from checking eligibility to managing enrollment to issuing ID cards.
  • Claims analysis and processing: We review and pay benefits with an eye on your bottom line – making sure we investigate complicated and high-dollar claims, and keeping track of large dollar amounts that might trigger your stop loss coverage to kick in.
  • COBRA/HIPAA/Compliance: Our experts will guide you on staying in compliance with rapidly shifting federal regulations and assist you in managing sensitive HIPAA data. We partner with industry leaders to provide specialty services such as COBRA administration.
  • Claims processing: Efficient, timely and accurate processing.
Customer Service

We work directly with plan participants to make sure they’re getting the most out of their plan. We provide members with all essential information in easy-to-understand formats, easing the workload on your HR team.

  • Secure, free online portal LINK TO portal page lets members check on claims status, review statements, locate providers, and look up coverage 24/7.
  • Free, secure mobile app offers quick overview of member benefits and claims.
  • Tollfree number to our customer service team.
  • Email access to support team.
Health Management Services

Our team of registered nurses provides pre-certs for procedures, assists with referrals, and performs large case management, in which they advocate for patients and help manage costs, procedures, and care of chronic and long-term conditions.

Pharmacy Benefit Management

HealthFirst has relationships with many industry-leading PBMs, allowing for seamless processing and payment of your group’s prescription drug benefits,  with support for both retail and mail-order options.

Underwriting And Stop Loss Coverage

Based on your employee population and the level of risk your group can assume, we will calculate recommended levels of reinsurance coverage. We work with many industry-leading reinsurance carriers and MGUs to obtain quotes on specific and aggregate stop loss policies that work seamlessly within your plan.


Employers and their brokers and consultants have instant access, via our secure online portal, to claims data, financials, and other reports that track how the employer’s healthcare dollars are spent.

Subrogation And Negotiation

We aggressively work to control your overall plan costs. We use subrogation to audit claims and recover any lost claim funds. Similarly, we take a proactive approach to negotiations with out-of-network providers, seeking discounts on the cost of services provided outside of the primary network.

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