What Happens With a Major Claim on Self-insurance Plans

by Tim AustinMarch 4, 2014 1:25 PM

Imagine you’re the CEO of a company with 49 employees. You’re currently covered through a fully insured health plan, but are considering switching to a self-insured group plan due to the potential premium increases resulting from the Affordable Care Act.  

All of the companies you know with self-funded plans are larger companies (250+employees), so you aren’t sure if this is the right solution for you. You’re also concerned that since you would pay self-insurance claims directly, your company could be liable for a major claim if an employee has a serious health issue. 

What do you think - what would you do in this situation? Before you make a decision, consider the following key points. 

What happens when you have a major claim on a self-insured policy?

The answer depends on the stop-loss insurance coverage.

How Stop-Loss Protects you From Major Unforeseen Claims 

  • Stop-loss insurance protects you from higher-than expected claim totals. If your group’s claim amount exceeds the self-funded limit, the stop-loss insurance provider will  pays the difference.

How Third Party Administrators (TPAs) Can Help

  • Reduce administrative tasks - TPAs administer the health plan by processing the claims, issuing ID cards,  and dealing with customer questions
  • Offer stop-loss with self-funded plans

Benefits of TPA Self-Funded Health Plans with GMS 

Creative, custom-tailored solutions for your employees 

  • Only pay for what you need - pay a specific amount into a claims fund each month
  • Stop-loss insurance included - you won’t have unexpected expenses in the event of a major claim 
  • One bill - streamline billing makes payments easy
Ok, so go back to the beginning and imagine you are that business owner again. 
Would you feel more comfortable making a decision with this information on TPAs and self-funded plans? Hopefully you’ll see that this option is not just for large companies—that this could be a time and money saving option for your company, too. 
If you’re interested in learning more about how GMS can help save your real company time and money with TPA services, let us know. We’re always here!

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