Strategic Solutions

Group Health Solutions Inc. is a full service employee benefits agency providing our clients with the expertise they need to navigate through the complex world of group and individual insurance.

Self-Funded Health Plans

All group medical benefit plans fall into one of two categories: self-funded or insured. The choice of one over the other should not be made arbitrarily. Each type carries its own set of administrative rules and legal constraints.

What is Self Funding?

Under an insured health benefit plan, an insurance company assumes the financial and legal risk of loss in exchange for a fixed premium paid to the carrier by the employer. Employers with self-funded (or self-insured) plans retain the risk of paying for their employees’ health care themselves, either from a trust or directly from corporate funds.

Many employers both large and small are looking at a self-funding solution now more than ever. With the power of having claims data to analyze as well as the ability through wellness programs to truly impact the health of your population self-funding your health plan is something your company should consider.

The risk assumed in either situation is the chance that employees will become ill and require costly treatment. When employees have few claims and few expensive illnesses, the self-funded employer realizes an immediate positive impact on overall health care costs. Conversely, if the employee group has unfavorable claims experience, a self-funded employer would incur an immediate expense beyond what may have been expected. Insured plans have a more predictable cost for the year; however, large employee claims costs from one year can affect future premium amounts.

Learn more about Self-Funded Health Plans

Private Exchange

Would you love to stop the agony of picking a health plan for a group of your employees but still want to sponsor a robust benefits program to recruit and retain the top talent?

A Defined Contribution, Employee Choice model combined with proven decision making support to simplify choices empowers employees to get the coverage they need and understand.

Do you want to expand your benefits offering but struggle to find the best way to deliver these benefits to your employees?

A private exchange enables you to offer a fortune 500 benefits model with the administrative simplicity you deserve.

Watch video to learn more!

Professional Employer Organizations (PEO)

Sometimes companies have trouble meeting their human resources needs, especially while also trying to increase profits. To assist in this area, many companies hire professional employer organizations (PEOs).

Would you like to cut health care costs, access jumbo company plans, outsource risk for labor law and benefits compliance for less than it would cost to hire a Senior HR Professional? Than a PEO might be for you.  With NYS keeping small group at 1-100 employees PEO’s are a potentially great solution for 51-99 size employers who have to deal with all the compliance of the ACA but are forced into buying health plans with community rated rates.

1. Human Resources Assistance
+ PEO acts as an off-site HR department by offering consulting in sexual harassment, discrimination, Family Medical Leave Act (FMLA), and hiring and firing practices + Conducts background checks and pre-employment testing on potential employees + Recruits employees through advertising, resume screening and interviewing + Provides customizable employee handbooks and position descriptions + Conducts performance reviews + Provides employee training for new positions
2. Employee Benefits Administration
+ PEO seeks out cost-effective benefits plans. By pooling all of its employees into one group (the vast array of companies hired by the PEO), the organization is able to spread their medical claims over a larger premium base. This equates to a lower annual rate increase, compared to smaller businesses. + PEOs typically offer the following benefit plans: Health care, Dental, Vision, Long- and short-term disability, Life insurance, 401(k), Section 125, COBRA compliance
3. Payroll Administration
The PEO will take responsibility for the following: + Payroll + Employee taxes + Quarterly reports + Workers’ compensation insurance + Premium audits + Claims management + Benefits procurement
4. Handling Risk Management
PEOs manage any workers’ compensation or unemployment claims that arise, typically at a lower claim cost (as compared to what a company could achieve on its own).

Telemedicine has become increasingly popular for your ever busy employee base. With our unique partnership with Pager we are able to provide our clients with access to phone consultations, onsite clinics and home dr. visits to give them greater access to care than they’ve ever had before.
ERISA vs State Regulation
ERISA vs State Regulation Self-funded health plans are governed by the Employee Retirement Income Security Act of 1974 (ERISA). ERISA preempts state insurance regulations, meaning that employers with self-funded medical benefits are not required to comply with state insurance laws that apply to medical benefit plan administrators. On the other hand, insured plans must comply with some of ERISA’s requirements, but are primarily governed by the state where covered employees reside. The distinction between state and ERISA regulations is important when determining if self-funding is right for your organization. Multi-state companies with insured health plans must comply with the regulations of each state in which they have plans and covered employees. Multi-state self-funded plans need only comply with ERISA.
Premium vs Unbundled Fees
The risk an insurance company takes with an insured plan can be translated into a dollar amount for the employer. That dollar amount is the premium an employer pays each month for the insured group medical benefits. The premium amount includes the following: + Current and predicted claims cost + Administrative fee + Premium tax paid to the state + Insurance company profit Employers who self-fund their medical benefits do not pay the premium tax or insurance company profit. They do, however, assume the costs of paying for claims and administrative functions. Typically, employers with self-funded health plans will outsource plan administration to a third party administrator (TPA) or insurance company who charges the employer a fee for performing administrative services. Stop-Loss Insurance Employers with self-funded health plans typically carry stop-loss insurance to reduce the risk associated with large individual claims or high claims from the entire plan. The employer self-insures up to the stop-loss attachment point, which is the dollar amount above which the stop- loss carrier will reimburse claims. Stop- loss insurance comes in two forms: individual/specific stop-loss and aggregate stop-loss. Individual/Specific Stop-Loss Insurance This protects a self-funded employer against large individual health care claims. Essentially, it limits the amount that the employer must pay for each individual. For example, an employer with a specific stop-loss attachment point of $25,000 would be responsible for the first $25,000 in claims for each individual plan participant each year. The stop-loss carrier would pay any claims exceeding $25,000 in a calendar year for a particular participant.
Aggregate Stop-Loss Insurance
This protects the employer against high total claims for the health care plan. For example, aggregate stop-loss insurance with an attachment point of $500,000 would begin paying for claims after the plan’s overall claims exceeded $500,000. Any amounts paid by a specific stop-loss policy for the same plan would not count toward the aggregate attachment point.
Non-Discrimination Rules
Non-discrimination rules require employers to offer employee benefits that do not favor certain employees. Employers with insured plans do not have non-discrimination rules for group medical benefits, provided they follow the policy requirements of the sponsoring insurance carrier. However, employers with self- funded plans are required to comply with non-discrimination rules. Generally these requirements are not difficult to meet, but failure to comply can result in some employees having their benefits treated as taxable income. Employers with either type of group medical plan are required to comply with certain reporting and disclosure requirements, usually by providing tax and other pertinent documents to the United States Department of Labor or to their particular state. Typically self-funded plans are required to provide copies of plan communications such as summary plan descriptions (SPDs) and summary of material modifications if the plan language changes. Employers with insured plans that require employee contributions must file certain financial documents with the U.S. Internal Revenue Service (IRS). IRS filings are also required of self-funded plans, including Form 5500 and any accompanying documents.