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A Comprehensive Guide to Level-Funded Health Insurance Plans

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A Comprehensive Guide to Level-Funded Health Insurance Plans

Understanding Level-Funded Plans, Cost-Containment, Flexibility

If you’re a small to medium-sized business owner diving into health insurance, figuring out how to provide valuable benefits to your employees without breaking the bank can feel like an impossible puzzle. Let’s simplify it: Level-funded health insurance plans are your secret weapon. In a nutshell, these plans offer the cost control and flexibility you’re looking for.

Level-funded plans are like the middle ground between traditional fully insured plans and self-funded ones. You pay a fixed monthly amount – this covers your claims fund, administrative costs, and stop-loss insurance. If claims are lower than expected, you could get money back at the end of the year. This structure gives you more predictability in budgeting and potential cost savings, all while maintaining a degree of protection against high claims.

Small and mid-sized businesses, who feel the pinch of rising healthcare costs the most, will find these plans particularly attractive. They offer a way to manage expenses while still providing high-quality health benefits – crucial for attracting and retaining top talent in today’s competitive marketplace.

Infographic showing the structure of Level-Funded Health Insurance Plans: Fixed Monthly Payment covers Administrative Costs, Claims Fund, and Stop-Loss Insurance. Potential for Year-End Surplus Refund if Claims are Low. Benefits: Cost Predictability, Savings, Flexibility. - level funded health insurance plans infographic pillar-3-steps

With a level-funded plan, you’re taking a step towards more transparent and manageable healthcare coverage. Not only do you gain insight into where your money goes, but you also get the chance to save if claims costs are lower than anticipated. It’s a smart strategy for businesses aiming to balance offering valuable employee benefits and maintaining financial health.

What is Level-Funded Health Insurance?

Level-funded health insurance plans are a smart choice for businesses looking to strike a balance between cost and coverage. They mix the best parts of two worlds: self-funded and fully insured plans. Let’s break it down in simple terms.


At its core, a level-funded health insurance plan is a type of employer-sponsored health coverage. Employers pay a fixed monthly amount, which covers administrative fees, stop-loss insurance, and an estimated amount for claims. This model offers a predictable cost, similar to a traditional fully insured plan, but with a twist: if claims are lower than expected, the employer may get a refund.

Self-Funded vs. Level-Funded

In a self-funded plan, an employer takes on the risk of paying out claims from their own pocket. This can be cheaper if claims are low, but risky if they’re high. Fully insured plans, on the other hand, pass all risk to the insurance company in exchange for a premium. Level-funded plans sit comfortably in the middle. They offer the potential cost savings of self-funding with the risk protection of stop-loss insurance, which kicks in if claims exceed a certain amount.

Hybrid Model

Think of level-funded health insurance as the hybrid car of health plans. Just as a hybrid car uses both gas and electricity to optimize efficiency and performance, level-funded plans use aspects of both self-funded and fully insured models to provide cost savings while minimizing risk.

Employers enjoy the predictability of fixed monthly payments, similar to a fully insured plan, but with the added perk of potentially getting money back, a feature more akin to self-funding. This hybrid model provides a safety net through stop-loss insurance, ensuring that if claims unexpectedly skyrocket, the business is protected from the financial blow.

Level-funded health insurance plans offer a middle ground solution for businesses cautious about the high risk of self-funding but seeking more control and potential savings than what fully insured plans typically offer. This approach aligns with the goals of many businesses aiming for more predictable healthcare costs without sacrificing the quality of benefits offered to employees. With level funding, businesses can enjoy the best of both worlds: the stability of predictable costs and the potential for savings if claims are lower than expected.

Key Components of Level-Funded Plans

When we talk about level-funded health insurance plans, we’re really diving into a model that’s designed to give businesses, especially small to mid-sized ones, a fair shot at managing their health care expenses effectively. Let’s break down the core components that make up these plans: Claims Account, Stop-Loss Insurance, Administrative Costs, and the potential for a Surplus Refund. Understanding these can help you see why level funding might be the right choice for your business.

Claims Account

Imagine you have a pot of money set aside specifically for the rainy day when someone needs medical care. That’s your Claims Account. Each month, part of your payment into the plan goes here, ready to be used when claims come in. It’s straightforward: money in, claims out. If the claims are less than expected, you’re in a good position, which leads us to another crucial component.

Stop-Loss Insurance

Now, what if it doesn’t just rain, but pours? Here’s where Stop-Loss Insurance comes in, acting like an umbrella on that stormy day. It’s your safety net, ensuring that if claims exceed a certain level, you’re not left covering the excess costs. This cap on your financial responsibility gives you peace of mind, knowing there’s a limit to what you’ll have to pay out in a year for claims.

Administrative Costs

Running a health plan isn’t just about paying claims; it involves a lot of behind-the-scenes work. Administrative Costs cover these operations, from handling claims and customer service to plan management. You’re essentially hiring experts to take care of the nitty-gritty, allowing you to focus on your business. It’s a cost-effective way to ensure your plan runs smoothly without needing to become an insurance expert overnight.

Surplus Refund

Here’s the cherry on top: the Surplus Refund. If your claims account ends the year in the green, meaning you’ve paid in more than was needed for claims, you might get money back. This refund is a potential bonus for managing your employees’ health effectively and another reason why level-funded plans can be more attractive than traditional fully insured options.

These components work together to create a health plan that offers predictability and control. You have a clear view of where your money’s going, protection against unexpected high costs, and even the chance to get money back if things go better than expected. It’s a balanced approach, providing the benefits of self-funding with the stability businesses need.

Keep these components in mind. They’re the building blocks of level-funded health insurance plans, offering a blend of cost containment, risk management, and potential savings that’s hard to beat. Whether you’re a startup or a growing business, understanding these key elements can help you make informed decisions about your health benefits strategy.

Next, we’ll explore the benefits these plans can offer to employers, from predictability and cost savings to compliance and transparency. Stay tuned.

Benefits of Level-Funded Plans for Employers

When it comes to providing health benefits, employers often find themselves in a tight spot, balancing cost with quality. Level-funded health insurance plans emerge as a beacon of hope, offering a slew of advantages that cater to the core needs of businesses, especially small to medium-sized ones. Let’s dive into the benefits such as predictability, cost savings, risk mitigation, ACA compliance, and transparency.


One of the standout features of level-funded plans is their predictability. Employers pay a fixed monthly fee, which encompasses the estimated claims, administrative fees, and stop-loss insurance. This setup means no surprises at the end of the month or year, making budgeting a breeze. Imagine knowing your expenses upfront, just like your Netflix subscription. It’s that level of predictability that makes level-funded plans so appealing.

Cost Savings

Next up, cost savings. This is where level-funded plans shine. If your employees’ health claims are lower than expected, your business could receive a refund at the end of the year. Think of it as a reward for having a healthy workforce. Moreover, the administrative costs are typically lower compared to fully insured plans. It’s a win-win, where you could potentially save money while still offering comprehensive health benefits.

Risk Mitigation

Risk mitigation plays a crucial role in the appeal of level-funded plans. The inclusion of stop-loss insurance protects your business from the financial strain of unexpectedly high claims. It’s like having a safety net, ensuring that the maximum out-of-pocket costs are capped, protecting your business from the volatility often associated with health care expenses.

ACA Compliance

Navigating the Affordable Care Act (ACA) can be daunting for any business. Level-funded plans ensure ACA compliance, offering essential health benefits and meeting the law’s requirements. This compliance not only safeguards your business from potential penalties but also ensures that your employees receive the quality care they deserve.


Lastly, transparency is a significant advantage. Unlike traditional fully insured plans, level-funded plans offer insights into where your health care dollars are going. Monthly reports on claims and utilization help you understand your workforce’s health trends, enabling you to make informed decisions about your health benefits strategy. This level of insight is invaluable in managing costs and improving employee health outcomes.

In conclusion, level-funded health insurance plans offer a compelling package of benefits for employers. From the predictability of fixed monthly payments to the potential for cost savings and the assurance of risk mitigation, these plans are designed with the needs of businesses in mind. Add to that the compliance with ACA mandates and the transparency in costs and utilization, and it’s clear why more employers are considering level-funded plans as a viable option for their health benefits strategy.

We’ll delve into how these plans compare to fully insured and self-funded options, shedding light on which might be the best fit for your business. Stay tuned.

Comparing Level-Funded, Fully Insured, and Self-Funded Plans

When it comes to choosing the right health insurance plan for your business, understanding the differences between level-funded, fully insured, and self-funded plans is crucial. Let’s break it down into simpler terms to help you make an informed decision.


  • Fully Insured Plans: Businesses pay a fixed premium to the insurance company. This premium is set for the year and doesn’t change, regardless of how many claims are filed.

  • Self-Funded Plans: There are no set premiums. Instead, the company pays for health claims out of pocket as they arise, which can vary significantly from month to month.

  • Level-Funded Plans: Employers pay a fixed monthly amount similar to a premium. This amount covers estimated claims, administrative fees, and stop-loss insurance. It combines predictability with the potential for cost savings.


  • Fully Insured Plans: The insurance company assumes all the risk. If claims exceed expectations, the insurer covers the costs.

  • Self-Funded Plans: The employer bears the full risk. High claims can lead to significant unexpected expenses.

  • Level-Funded Plans: Risk is mitigated through stop-loss insurance, which protects employers from high claims. This offers a middle ground between the predictability of fully insured plans and the risk of self-funded plans.

Administrative Responsibilities

  • Fully Insured Plans: The insurance company handles all administrative tasks, making this the easiest option for businesses without a dedicated HR department.

  • Self-Funded Plans: The employer is responsible for all aspects of the health plan, including claims processing and compliance. This requires a significant administrative effort or the need to hire a third-party administrator.

  • Level-Funded Plans: While employers retain some administrative responsibilities, much of the heavy lifting is handled by the third-party administrator, easing the burden on businesses.

Potential Savings

  • Fully Insured Plans: Employers pay a premium that may include a margin for the insurer’s profit and risk. There’s little opportunity for savings if claims are lower than expected.

  • Self-Funded Plans: Employers can save significantly if claims are lower than anticipated but can also face higher costs if claims are higher.

  • Level-Funded Plans: If claims are lower than expected, employers may receive a refund on the claims portion of their payments. This offers a way to save on healthcare costs without assuming the full risk of a self-funded plan.

In summary, level-funded health insurance plans offer a unique blend of the predictability and simplicity of fully insured plans with the potential cost savings of self-funded plans. They provide a way for businesses to control healthcare costs while mitigating the risk of high claims. For companies looking for a middle ground, level-funded plans are worth considering.

As we explore further, keep in mind how these differences align with your business’s financial stability, risk tolerance, and administrative capacity. Moving on, we’ll discuss how level-funded plans comply with the Affordable Care Act and what that means for your business.

How Level-Funded Plans Work

Let’s dive into the nuts and bolts of level-funded health insurance plans. These plans are like a bridge, connecting the worlds of self-funded and fully insured plans. They provide a unique approach to managing health benefits for your team. Here’s how they work:

Monthly Payments

Imagine you’re paying a fixed amount every month, just like a subscription service. This is what happens with level-funded plans. Each month, your business pays a set fee. This fee covers three main areas:
Claims fund: Money set aside for employee health claims.
Stop-loss insurance: A safety net for when claims exceed expected amounts.
Administrative costs: Payment for the third-party administrator who manages the plan.

This predictable monthly payment helps businesses budget better, without the fear of unexpected healthcare costs.

Claims Processing

When an employee makes a health claim, the funds come from the claims account you’ve been contributing to each month. It’s straightforward: the third-party administrator handles the paperwork and processes the claim. If the total claims stay under the threshold you’ve set, everything runs smoothly.

But what happens if claims go over that threshold? That’s where stop-loss insurance comes into play. It covers the excess, protecting your business from high costs due to unexpected health issues.

Refund Opportunities

Here’s where it gets interesting. At the end of the year, if your employees’ health claims didn’t use up all the funds in the claims account, your business might get a refund. That’s right, money back in your pocket. This is a key difference from fully insured plans, where any unused premiums simply stay with the insurance company.

This refund opportunity is a big deal. It encourages businesses to invest in wellness programs and preventive care. Healthier employees mean fewer claims, and fewer claims could mean refunds for your business.

In summary, level-funded health insurance plans offer a blend of predictability, cost savings, and the chance to get money back if claims are lower than expected. For businesses looking for more control over their health benefits spending, level-funded plans are a compelling option. They strike a balance between the risk of self-funding and the predictability of fully insured plans, with the added bonus of potential refunds.

Keep these mechanics in mind. They’re the foundation of how level-funded plans can be a strategic choice for your business. Next, we’ll look into how these plans align with ACA compliance and what that means for offering competitive, comprehensive benefits to your employees.

Level-Funded Plans and ACA Compliance

Understanding how level-funded health insurance plans align with the Affordable Care Act (ACA) requirements is crucial for employers. Let’s break it down into simple terms, focusing on Essential Health Benefits, Minimum Essential Coverage, and Preventive Services.

Essential Health Benefits

First off, Essential Health Benefits. The ACA specifies that all health plans must cover a set of 10 essential health benefits. These include services like outpatient care, emergency services, hospitalization, and prescription drugs. Level-funded plans, like other forms of health coverage, must adhere to this rule. This ensures that employees receive a comprehensive package of services that meet a minimum standard of care.

Minimum Essential Coverage

Next, we have Minimum Essential Coverage. This part of the ACA mandates that health plans provide coverage that meets the law’s requirements to avoid penalties. For employers, this means offering plans that cover at least 60% of the total allowed costs of benefits. Level-funded plans are designed to meet or exceed these standards, providing peace of mind that your business is compliant with ACA regulations.

Preventive Services

Lastly, Preventive Services. The ACA places a strong emphasis on prevention, requiring plans to cover preventive services at no charge to the patient. This includes screenings like blood pressure, diabetes, and cholesterol tests, as well as vaccines and cancer screenings. By covering these services, level-funded plans not only comply with ACA mandates but also promote healthier lifestyles among employees, potentially reducing overall healthcare costs in the long run.

preventive healthcare services - level funded health insurance plans

Why This Matters

For employers, ensuring that your health plan is ACA compliant isn’t just about avoiding penalties; it’s about offering quality care that supports the well-being of your employees. Level-funded health insurance plans are structured to align with ACA requirements while providing the flexibility and potential cost savings that businesses value. This makes them an attractive option for employers looking to balance compliance, cost control, and comprehensive care.

As we transition to the next section, compliance with the ACA is just one piece of the puzzle. The right level-funded plan can also offer customization and additional features that enhance employee health and engagement, further contributing to a positive workplace culture and a successful business.

Next Up: Choosing the Right Level-Funded Plan – Here, we’ll explore how to select a plan that fits your company’s unique needs, including customization options and considerations for network-only or reference-based pricing plans.

Choosing the Right Level-Funded Plan

When it comes to level funded health insurance plans, there’s no one-size-fits-all solution. Your business is unique, and so are your health plan needs. Let’s dive into how you can select the best plan for your organization, focusing on plan options, customization, PPOs, network-only plans, and reference-based pricing.

Plan Options

Level funded health insurance plans come with a variety of options. You can choose from basic plans covering essential health benefits to more comprehensive plans that include wellness programs, telemedicine, and more. The key is to assess your employees’ needs and your budget. The goal is to offer a plan that not only meets ACA compliance but also supports your employees’ health and well-being.


One of the biggest advantages of level funded plans is their flexibility. You’re not stuck with a pre-packaged plan. Instead, you can tailor aspects of your coverage to better match your workforce’s demographics and health needs. For instance, if your team is young and healthy, you might prioritize preventive care and wellness programs. On the other hand, if you have a diverse age group, you might opt for a plan that offers a broader range of services.

Preferred Provider Organizations (PPOs)

PPO plans are popular for a reason. They offer flexibility in choosing healthcare providers. Employees are not required to select a primary care physician and can see specialists without a referral. This type of plan is ideal for businesses looking to offer more healthcare freedom to their employees. However, it’s crucial to weigh the costs, as PPOs can be more expensive than other options.

Network-Only Plans

Network-only plans, such as HMOs, might be a more cost-effective solution for some businesses. These plans usually require employees to choose a primary care physician within the network and get referrals to see specialists. The trade-off for the lower cost is less flexibility. If a significant portion of your workforce is concentrated in one geographic area with good network coverage, this could be a viable option.

Reference-Based Pricing

Reference-based pricing is a bit different. It sets a maximum amount the plan will pay for certain services. This approach encourages employees to shop around for their healthcare, potentially saving money for both them and the employer. However, it also requires more engagement from employees in their healthcare decisions, which might not suit everyone.

Choosing the right plan involves understanding your workforce’s needs, your company’s financial health, and the trade-offs between cost, flexibility, and coverage. It’s not just about the bottom line; it’s about finding a balance that works for everyone involved.

Next Up: Additional Features and Programs – Beyond the basic coverage, level funded health insurance plans can offer a range of features aimed at improving health outcomes and reducing costs. We’ll take a closer look at what’s available, from telemedicine to wellness programs, and how they can benefit your business and your employees.

Additional Features and Programs

When we peel back the layers of level funded health insurance plans, we uncover a treasure trove of additional features and programs designed not just to protect, but to proactively improve the health of employees. Let’s dive into some of these features and understand how they contribute to a healthier, happier workforce and, ultimately, to cost reduction for employers.


In today’s world, telemedicine has emerged as a game-changer. It allows employees to consult with healthcare professionals via phone or video chat. This means they can get medical advice without the need to travel or sit in waiting rooms. For employers, this translates to less time away from work for employees and quicker access to care, which can help in managing health issues before they escalate.

Wellness Programs

Wellness programs are at the heart of preventive care. They can range from smoking cessation programs and fitness challenges to stress management workshops. The goal is simple: to keep employees healthy and reduce the need for medical interventions. Programs like Wellbeats, which offer on-demand fitness, or initiatives aimed at managing chronic conditions like diabetes, underscore the commitment to keeping the workforce active and informed about their health. Healthy employees mean fewer claims, which can lead to savings for employers.

Member Engagement

Engaging employees in their own health care is crucial. Member engagement initiatives can include educational resources, personalized health plans, and regular health assessments. By understanding their health better, employees can make informed decisions about their care. This not only improves their well-being but also fosters a culture of health within the organization. Engaged employees are more likely to participate in wellness programs and comply with preventive measures, further driving down healthcare costs.

Cost Reduction

All these features contribute to cost reduction, the cornerstone of level funded health insurance plans. By focusing on preventive care, providing access to telemedicine, and engaging employees in wellness programs, businesses can mitigate health risks and reduce the frequency and severity of claims. This proactive approach can lead to significant savings, especially when coupled with the financial predictability and risk mitigation inherent in level funded plans.

These additional features and programs are not just add-ons; they are integral components of a comprehensive health care strategy that benefits both employees and employers. They underscore the symbiotic relationship between a healthy workforce and a healthy bottom line.

Remember that choosing the right level funded plan for your organization means looking beyond the numbers. It means considering how these additional features can enhance the well-being of your employees and, by extension, the success of your business.

Frequently Asked Questions about Level-Funded Health Insurance Plans

When exploring health insurance options, you may come across terms that seem complex. Level-funded health insurance plans are one such term that’s gaining attention for their unique benefits. Let’s dive into some common questions employers have about these plans.

What is the difference between level funded and fully insured plans?

Level funded plans are like a middle ground between self-funded and fully insured plans. Here’s a quick breakdown:

  • Fully Insured Plans: You pay a fixed premium to an insurance company. They handle all your claims and assume all the risk. It’s simple and predictable, but often more expensive and less flexible.

  • Level Funded Plans: You pay a fixed monthly amount, like in fully insured plans, but this includes a portion for claims. If claims are lower than expected, you might get a refund. It offers more control and potential savings.

How do level-funded plans offer cost savings to employers?

Level-funded plans can save money in several ways:

  1. Refunds: If your claims are lower than the funds allocated, you might get money back. This is a feature not typically available in fully insured plans.

  2. Lower Premiums: Since level-funded plans are partially self-funded, they often have lower premiums compared to fully insured plans.

  3. Control Over Benefits: You have more flexibility to tailor the plan to your needs, potentially avoiding paying for unnecessary coverage.

Are level-funded plans ACA compliant?

Yes, level-funded plans are designed to comply with the Affordable Care Act (ACA). They cover essential health benefits and preventive services, just like fully insured plans. This means you can offer a level-funded plan and still meet the legal requirements for providing health insurance to your employees.

While level-funded plans can offer significant advantages, they also require you to take on a bit more responsibility. You’ll be more involved in managing the plan and may share in the risk. However, with the right support and understanding, a level-funded plan can be a smart choice for many businesses looking to balance cost savings with comprehensive coverage.

As we conclude this section, it’s clear that level-funded health insurance plans offer a compelling option for employers seeking flexibility, potential cost savings, and ACA compliance. Whether you’re a small startup or a growing mid-sized business, these plans can provide the financial predictability and benefit customization you need to support your team’s health and your company’s bottom line.


As we’ve explored the ins and outs of level-funded health insurance plans, it’s clear they represent a strategic choice for businesses aiming to balance cost control with comprehensive employee benefits. At NPA Benefits, we understand that navigating health insurance can be complex. That’s why we’re committed to offering solutions that not only meet your immediate needs but also support your long-term goals.

Attracting and Retaining Employees

In today’s competitive job market, offering attractive benefits is crucial for drawing in top talent and keeping them. Surveys have shown that a significant percentage of employees consider the quality and options of health benefits important when choosing a job. Moreover, with a workforce that increasingly values flexibility and comprehensive coverage, level-funded plans stand out as a benefit that can help set your company apart. By providing plans that offer both cost savings and flexibility, you’re showing current and prospective employees that you value their health and well-being. This can be a powerful tool in both attracting and retaining the skilled individuals who drive your business forward.

Long-Term Solutions

Choosing a level-funded health insurance plan is not just about meeting the current needs of your business and its employees; it’s also about positioning yourself for the future. As your company grows and evolves, the adaptability and potential cost savings of level-funded plans can provide a stable foundation for your benefits strategy. With options to customize plans and the opportunity for refunds on unused claims funds, these plans are designed to grow with you, offering a solution that can adapt to changing needs over time.

At NPA Benefits, we’re dedicated to helping you find the right level-funded health insurance plan that aligns with your business goals and employee needs. Our expertise and commitment to quality service mean that you can trust us to guide you through the selection process, ensuring that you’re making an informed decision that benefits everyone involved.

For more information on how level-funded health insurance plans can benefit your business and to explore the options available, visit our services page on health insurance benefits. Let us help you find the solution that supports your team’s health and your company’s success, today and into the future.

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