GBS Infographic •Common Payment Models

Overview of Common Payment Models

Group Benefits Strategies is here to help! Contact us today at (508) 832-0490 for more information.


  • The carrier assumes the financial risk of providing health insurance, and the employer is charged a flat monthly fee.
  • The employer typically knows the costs ahead of time since it pays a flat fee every month.
  • Fully insured plans are subject to state rules and regulations.
  • With this type of payment model, costs are unlikely to decrease, even with a low previous-year utilization.


  • The employer assumes the financial risk of providing health insurance and pays for medical claims out of pocket.
  • These models can be more easily customized to fit the specific needs of an employer’s workforce.
  • The employer can contract with providers, or a particular provider network, that will best meet the needs of its employees.
  • The employer will typically work with a third-party administrator (TPA), which assumes claims administration duties.
  • Self-insured health plans are not subject to state health laws, but rather federal laws. These plans are not subject to state health insurance premium taxes.


  • Level funding models are sometimes thought of as a hybrid of fully insured and self-insured payment models.
  • In this type of model, the employer pays a set amount each month to a carrier, and the carrier then pays employees’ claims throughout the year.
  • If the employer’s monthly payments exceeded the amount of claims filed, the employer will receive a refund from the excess they paid in monthly claim allotments. If the employer’s monthly payments did not exceed the amount of claims filed, stop-loss insurance will typically cover the overage amount, if allowed by state law.
  • Typically, an employer will be assisted or advised by a TPA on the previous two bullet points.
  • Companies with smaller numbers of employees may benefit differently than those with larger numbers.

Latest ACA Repeal Bill Withdrawn


By GBS Team

The Graham-Cassidy bill, the most recent Republican effort to repeal and replace the Affordable Care Act (ACA), was withdrawn from a vote on Sept. 26 due to lack of support in the Senate,
effectively dooming the legislation. Earlier that week, key Republican senators voiced opposition to the bill, which forced Senate leadership to shelf the vote until further notice. Given the
vocal opposition from influential health organizations and lawmakers on both sides of the aisle, the proposed bill would need a variety of amendments before plausibly moving forward.

This means the ACA will almost certainly remain unopposed until 2018. Republicans are using the remainder of the year to focus on a tax overhaul and do not have the bandwidth to continue the repeal and replace effort that has consumed most of this year.

With this latest repeal failure, more and more lawmakers are pushing for bipartisan negotiations to fix the flaws in the current health system. Democrats hope this most recent repeal failure will
increase their bargaining position, since they were largely ignored during all the health bill drafting sessions this year. If Republicans cannot secure enough of their members’ votes, they will be forced to negotiate with their counterparts.

What This Means for Employers

The IRS confirmed recently that employers should continue to comply with any ACA mandates, including the individual mandate and the employer shared responsibility rules. The IRS clarified this after the uncertainty created by President Donald Trump’s initial executive order directing federal agencies to provide relief from the burdens of the ACA.

Infographic – Hospital Indemnity Coverage

This infographic provides a brief overview of hospital indemnity coverage and its benefits for employees and is provided to you courtesy of Group Benefits Strategies.

Hospital indemnity insurance is a type of plan that pays a set amount – per day, per week, per month, or per visit – if you’re confined in a hospital. The Hospital Cash Plan is a hospital indemnity insurance plan.

To download for print, please click the link button below.

Questions about Hospital Indemnity Coverage?

15 + 10 =

GIC Update


By Christopher Nunnally, LIA

Chris Nunnally is an Account Executive with Group Benefits Strategies.

Chris has been working in insurance and benefits his entire career. He was formerly the Director of Broker Sales for Teladoc. Prior to that, he was a Sales Representative for Sun Life Financial and New York Life where he gained extensive knowledge of Employee Benefits and Stop Loss Insurance.

The Group Insurance Commission (GIC) was established by the Legislature in 1955 to provide and administer health insurance and other benefits to the Commonwealth’s employees, retirees, and their dependents. The City of Springfield would later become the first municipality to enroll in the state’s health insurance plans beginning January 1, 2007. Today, 61 public entities are part of the state-run group health insurance plan.

Municipality’s rationale for joining the GIC is to save money on healthcare cost, alleviate the burden of administrating a health plan, and offer a wide choice of insurance plans. Today there are 6 carriers offering 12 plans including several prescription drug choices.

Earlier this year the GIC froze enrollment in the Tufts Navigator and Fallon Health Select plans leaving fewer choices available to members. This is in addition to the already frozen Harvard Pilgrim Independence plan. Blue Cross Blue Shield of Massachusetts, a popular carrier among many municipalities, is not offered by the GIC.

The GIC’s current consultant recently presented initial recommendations for the future. In short, the recommendations are to limit prescription drug choice to one PBM and explore the further narrowing of its carrier and plan options. Wide choice in plan designs with several carriers that once was a hallmark of the GIC will give way to fewer plan designs and fewer carriers, again leaving its members with fewer healthcare choices available to them.

It’s a new day in the GIC and municipalities will have to ask, “Is it time to give or take control of their healthcare future?”

COBRA Common Questions: Definitions

The Consolidated Omnibus Budget Reconciliation Act (COBRA) allows individuals to continue their group health plan coverage in certain situations. Specifically, COBRA requires group health plans to offer continuation coverage to covered employees and dependents when coverage would otherwise be lost due to certain specific events, such as a termination of employment, a divorce or the loss of dependent status under the terms of the plan.

COBRA sets rules for how and when continuation coverage must be offered and provided, how employees and their families may elect continuation coverage and when continuation coverage may be terminated.

Employers may require individuals to pay for COBRA coverage. Group health coverage for COBRA participants is usually more expensive than coverage for active employees, since many employers pay a part of the premium for active employees.

What employers are subject to COBRA?

Employers who employed 20 or more employees on more than 50 percent of the business days in the prior calendar year are subject to COBRA.

Small-employer plans, church plans and governmental plans are not subject to COBRA. However, state and local governments are required to comply with parallel continuation coverage requirements under the Public Health Service Act. Individuals covered under the Federal Employees Health Benefit Program are provided with similar, but not identical, rights to continue coverage.

What is a small employer plan under COBRA?

A small employer plan is a health plan maintained by an employer that normally employed fewer than 20 employees during the preceding calendar year.

An employer is considered to have normally employed fewer than 20 employees during a particular calendar year if, and only if, it had fewer than 20 employees on at least 50 percent of its typical business days during that year. For purposes of determining whether or not an employer has 20 or more employees, all employees of all related employers under common control with the plan sponsor must be counted. Employers with a parent-subsidiary or brother-sister relationship with 80 percent common ownership are treated as one employer under COBRA.

Small employer plans are not subject to COBRA for the years in which they qualify for this exception. However, if a plan has been subject to COBRA and becomes a small employer plan, the plan remains subject to COBRA for qualifying events that occurred during the period when the plan was subject to COBRA.

For purposes of COBRA, who is an employee?

For purposes of determining whether an employer is subject to COBRA, employee means only common law employees. Therefore, self-employed individuals, independent contractors and directors are not counted when determining whether an employer is subject to COBRA. The term employee means any individual working for the employer, including part-time and full-time employees, regardless of whether the employee has enrolled in the health plan or is eligible for health insurance.

For purposes of determining how many employees an employer employs, part-time employees may be counted as a fractional employee, with the fraction being equal to the number of hours worked divided by the number of hours that an employee must work in order to be considered full time. However, an employer may not consider a full-time employee as an individual working more than 40 hours a week for purposes of this calculation.

What is a health plan under COBRA?

A health plan is a plan maintained by an employer or employee organization to provide health care to individuals who have an employment-related connection to the employer or employee organization or to the families of such individuals. Individuals with an employment-related connection include employees, former employees and their family members.

A plan is considered to provide health care whether it does so directly or through insurance, reimbursement or other means, and whether it does so through an on-site facility or cafeteria or other flexible benefit arrangement. Insurance includes one or more individual policies under an arrangement maintained by an employer to provide health care to two or more employees.

Health care includes diagnosis, cure, mitigation, treatment or prevention of disease, and any other services or care for the purpose of affecting any structure or function of the body. Plans covering the following are generally considered health plans under COBRA:

• Medical or surgical care
• Prescription drugs
• Dental care
• Vision care
• Hearing care
• Drug and mental health treatment

Health flexible spending arrangements (FSAs) and health reimbursement arrangements (HRAs) are also health plans. Some health savings accounts may be considered health plans, but the IRS has indicated that COBRA does not apply to these accounts.

Qualified Beneficiaries – Who is a qualified beneficiary?

A qualified beneficiary is any individual who, on the day before the qualifying event, is covered under a health plan by virtue of being on that day either:

  • An employee;
  • A spouse of a covered employee;
  • A dependent child of the covered employee*; or
  • Any child who is born to or placed for adoption with a covered employee during a period of COBRA continuation coverage.