How does group health insurance differ from a self-funded plan?

Group health insurance plans:

  • A health insurer issues a policy outlining what is and is not covered.
  • Benefits are outlined in the policy as well as deductibles and co-pays. Terms are not negotiable.
  • Insurance has a fixed premium in effect for the term of the policy.
  • The employer pays the premium to confirm policy acceptance.
  • Workers often contribute toward the group insurance premium through payroll deduction.
  • Group insurance contracts are subject to the state insurance regulatory agency in the state where the policy was issued.

Self-funded health plans:

  • Employer assumes the risk (rather than an insurance company) by setting money aside to pay workers' health care costs.
  • Benefits are outlined in a plan document created by the employer.
  • The cost of the plan may need to be adjusted mid-year.
  • A third-party administrator often administers the self-funded health plan and processes claims.
  • Self-funded insurance (except those sponsored by school districts, municipalities and churches) must comply with federal laws including ERISA.