BENECRAFT KNOWLEDGE CENTER
A practical field guide to group benefits, self-funding and the work behind a successful health plan.
34 articles · All Topics
The employer finances covered claims and hires partners to administer the plan. The funding arrangement and the benefit design are separate decisions.
An employer pays an insurer premiums for covered benefits; the insurer assumes the insured claims risk.
A self-funded arrangement commonly combining scheduled claims funding, administration and stop-loss premiums into a regular payment.
A practical decision process that tests affordability, risk and operational readiness.
The amount a member pays for applicable covered services before specified plan benefits begin paying.
A copay is a specified member charge; coinsurance is a percentage of an applicable covered amount.
A limit on qualifying member cost sharing over a defined period.
Three different tax-favored ways to pay or reimburse eligible health expenses.
Compare the member experience alongside the employer budget.
Paid claims follow payment dates; incurred claims follow when covered services occurred.
Incurred but not reported (IBNR) estimates recognize claims not yet reported. Run-out is the period in which earlier claims continue to be processed or paid.
PEPM means per employee per month; PMPM means per member per month, including covered dependents.
Trend describes changes in cost over time; large claims can disproportionately influence a small population.
Expected cost is an estimate of a typical outcome. Modeled liability describes an adverse outcome under explicit assumptions.
A third-party administrator (TPA) provides contracted plan administration. Administrative services only (ASO) describes an administrative arrangement rather than insured claims coverage.
A PBM administers pharmacy benefits under a contract with the plan or another administrator.
A formulary identifies covered drugs and applicable rules; specialty pharmacy programs address complex or high-cost therapies.
A network is a set of provider arrangements, not a promise that every local doctor participates.
Match a targeted service to a documented need and measurable outcome.
Specific coverage addresses eligible claims above a per-person threshold; aggregate coverage addresses eligible total claims above a contractual attachment point.
Incurred and paid windows determine which claims can qualify for reimbursement.
A laser is an individual-specific stop-loss limitation, such as a higher deductible or exclusion, defined by the policy.
Compare coverage on an equivalent basis before ranking premium.
Many private-employer health plans are subject to ERISA. Plan administration includes duties that cannot be evaluated from a software checklist alone.
These documents serve different purposes: governing terms, participant explanations and standardized benefit comparisons.
Federal COBRA can provide temporary continuation after qualifying events for eligible beneficiaries of covered group plans.
HIPAA includes group-plan portability and nondiscrimination protections as well as separate health-information privacy and security rules.
A qualifying written cafeteria plan can let employees choose between taxable compensation and eligible tax-favored benefits.
Federal protections address certain surprise medical bills, including qualifying emergency services and certain care at in-network facilities.
Federal transparency rules establish disclosure obligations for many health plans and insurers.
A renewal is a coordinated review of current benefits, experience, alternatives and implementation needs.
A request for proposal gives vendors a consistent basis for responding.
A census describes a population; enrollment records identify benefit elections and coverage tiers.
Implementation converts an approved decision into a working benefit program.