health insurance

By Chris Noffke, GBDS, CSFS, Vice President of Employee Benefits

Health insurance premiums are constantly on the rise. According to the Centers for Medicare & Medicaid Services, “U.S. health care spending grew 2.7 percent in 2021, reaching $4.3 trillion or $12,914 per person.” Everyone from employees to employers are feeling the squeeze of high-cost premiums. As rising premiums keep employers frustrated, benefits-users are also enduring less and less being paid by insurance. Business owners are having to make decisions like sacrificing benefits to save money on premiums to afford higher wages. Many employers are asking if they should self-fund. 

Having a really big company with lots of the employees covered by the health plan means these employers have more money being paid into the premium pools – the basic rule of large numbers. In Wisconsin, any group with more than 50 employees is considered a large group and is not qualified for the Affordable Care Act marketplace plans. While companies with as few employees as 50 may qualify for a self-funded benefit, it could also be a liability that causes a business bankruptcy. An employer can hedge their premium dollars against only having a few high-cost health care claims per year. These same strategies don’t work for smaller companies, because they may not have many employees enrolled in the health plan (especially if the employer contributions are too low) which means they have even fewer premium dollars to cover when their work family does have a high-cost claimant(s).

For example, if a smaller group (50 employees for this scenario) has a high-cost claimant who costs $50,000 a year, that means a lot of your collected premiums are needed just to cover this one claimant. Assuming an average employee premium of $1,000 a month per employee (averaging employee and family), your employer premiums are $50,000 a month ($600,000 a year). That means one employee used one-twelfth of your premium funds.

In our example we have only covered $50,000 in claims and we still have 49 remaining insureds who may each spend the $12,914 average. The math, 49 persons at $12,000 means $588,000 potential you may have to pay. This is not yet taking into account that there are multiple people in your employee’s families who may have claims.

It is not just claims you pay for when you are self-funded, you are also responsible to pay for a selected insurance company or third party administer (TPA) to process your groups’ claims, your use of a network for discounts, a pharmacy benefit manager, stop loss insurance, Patient-Centered Outcomes Research Institute (PCORI), terminal liabilities, aggregate accommodations and other administrative costs just to name a few.  This all may not make sense yet or it might sound like another language. Just let me know and we can talk. Give me a call at 608.442.3734. While true self-funding may not be the best answer for your company, utilizing strategies, other funding arrangements and even our association health plan may be a solution.