Control costs and customize health insurance coverage with a self-funded plan.
About Self-Funded Plans for Businesses
In self-funded plans, businesses cover employee medical costs directly. Today, 59% of companies in the United States use self-funded plans to provide their employees with health coverage.
How it Works
With self-funded plans, businesses can choose to pay medical claims as they are incurred or deposit expected costs each month. If there are funds left over after all claims are paid, companies can keep the difference. Self-funded plans from The Health Plan can cover companies with as few as 25 employees.
Self-funded plans enable businesses to choose the coverage that best meets their budget and their employees’ needs. They also allow you to mimic the structures and benefits of your current plan, or build a custom plan to fit your company.
The Health Plan can administer your self-funded health insurance, which gives your employees access to our national PPO networks.
Stop Loss Insurance
The Health Plan can also help you secure stop-loss insurance, either through our company or one of our partners. Stop-loss insurance protects you from catastrophic claims. We have a dedicated team in place to manage your stop-loss coverage and help control your health care costs.
Your Rights & Protections Against Surprise Medical Bills
When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.
You Have These Protections
When balance billing isn’t allowed, you also have the following protections:
- You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.
- Your health plan generally must:
- Cover emergency services without requiring you to get approval for services in advance (prior authorization).
- Cover emergency services by out-of-network providers.
- Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
- Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.
You are Protected from Balance Billing
You are protected from balance billing for:
If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
This notice was written by federal agencies. It is intended to provide you with a brief summary of some of the protections provided by the federal No Surprises Act. The laws in certain states may also provide protection from surprise billing.
Certain services at an in-network hospital or ambulatory surgical center
When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.
If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.
You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.
What is Balance Billing?
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.
“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.
“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.