What’s the Real Cost of Staying Fully Insured?
Your Guide to Self-Funding with Fox Everett
Fully insured plans might seem simple. However, that simplicity often has a high, hidden cost. With rising premiums, lack of transparency, and uniform coverage, many employers end up paying too much without achieving better results. At Fox Everett, we help you understand what self-funding really means and how it can provide more control, flexibility, and savings. This guide will walk you through the basics, so you can make smarter, informed decisions for your benefits strategy.
$150M+
in Annual Claims
80+
Years of Expertise
24,000+
Members
Part 1: Breaking Free from the Status Quo
Too many employers accept rising costs, limited flexibility, and outdated insurance models as the norm. But there’s a better way. In this section, we uncover how self-funding challenges the conventional system—giving you more control, transparency, and long-term savings. It’s time to rethink what’s possible and build a benefits strategy that works for your business—not against it.
Why Traditional Insurance Is Broken
Fully insured health plans continue to frustrate employers. Every year, youface premium increases—often with little explanation or control. Benefits getworse, costs go up, and HR teams are left managing unhappy employees with fewerresources. Sound familiar?
Self-funded health plans flip the script by returning control, cost-transparency, and customization to the employer. Instead of pre-paying a fixed premium to a carrier (who profits off your unused claims), self-funded employers pay for the healthcare their team actually uses. This isn’t just cost-cutting—it’s a smarter strategy for sustainable benefits.
What Is a Self-Funded Plan?
A self-funded (or self-insured) plan is when an employer assumes the direct cost of employee healthcare claims, typically with protection from catastrophic loss through reinsurance (stop-loss insurance). You choose your vendors—including TPA, PBM, reinsurance, and network—and can design a benefits experience that fits your population and budget.
Core Benefits of Self Funding
Claims transparency & analytics
Custom plan design
Better vendor pricing and contracts
Stop-Loss Protection
Long-term cost containment
Who Is a Good Fit for Self-Funding?
Self-funding used to be limited to large companies. Not anymore. Employers with as few as 50 enrolled employees can leverage this model, especially with the right advisor and risk pooling strategies in place (e.g., group captives).
Great Candidates include:
Mid-sized companies (50–500 employees)
Employers frustrated by fully insured renewal cycles
HR teams seeking plan flexibility
CFOs looking for data to support cost decisions
Key Concepts You Should Know
Navigating self-funded insurance can feel overwhelming at first—especially with so much industry jargon. But understanding the key terms is the first step toward making smarter, more confident decisions for your organization. This glossary was built for employers, CFOs, and HR leaders looking to break free from confusing carrier language and take control of their health plans. From stop-loss to claims adjudication, we’ve defined the most important terms in plain English, so you can lead every benefits conversation with clarity and confidence.
An arrangement where employers directly fund their employees’ healthcare claims instead of paying fixed premiums to an insurance carrier. Offers cost control, transparency, and customization options.
Similar to medical self-funding, this allows employers to directly fund dental and vision benefits—often yielding cost savings and more plan design flexibility.
The process of handling and paying out claims under a self-funded plan. Often delegated to a Third Party Administrator (TPA) who processes claims, manages reporting, and ensures regulatory compliance.
A service partner who handles claims processing, reporting, member support, and regulatory compliance for self-funded employers. TPAs allow employers to focus on strategy while offloading operations.
Preferred Provider Organizations (PPOs) are networks ofhealthcare providers that offer negotiated rates. Employers choose networksbased on access, value, and geographic coverage.
A cost-control strategy where claims are reimbursed based ona fixed benchmark (e.g., 140–180% of Medicare), rather than inflated hospitalcharges. Offers substantial savings and pricing transparency.
PBMs manage prescription drug plans. Fox Everett partnersonly with transparent, pass-through PBMs that provide clear visibility intopricing, rebates, and formulary design.
The process of securing stop-loss insurance to protect self-funded plans from catastrophic claims. Fox Everett negotiates tailoredcontracts based on actual risk—not templates.
Supplemental health plans that help cover out-of-pocketcosts not covered by primary medical insurance. Popular among employers looking to offer richer benefits affordably.
Federal legislation requiring continued coverage foremployees after separation from employment. Fox Everett ensures full complianceand handles notices, payments, and reporting.
IRS code allowing employees to pay for benefits usingpre-tax dollars. Includes premium-only plans, FSAs, and dependent care. FoxEverett manages setup, compliance, and administration.
A set of clinical services designed to improve outcomes forhigh-risk or chronically ill members while reducing avoidable costs throughproactive, coordinated care.
Using data analytics to forecast future health risks andcosts across an employee population. Helps employers tailor wellness programs,interventions, and benefits strategy.
Win More Business with a True Back-Office Partner
Bring your prospects a smarter strategy and a smoother process. From plan modeling to claims support, Fox Everett delivers the flexibility and transparency that today’s clients expect—and producers need to stand out. Let’s talk through how we help you close deals with confidence.
What Makes Fox Everett Different?
At Fox Everett, we don’t believe in one-size-fits-all benefits. We combine national strength with boutique service to deliver smarter, self-funded plans built around your specific needs. Our clients get more than just a broker—they get a strategic partner with real humans, real data, and real results. From the first coverage review to long-term plan performance, we’re here to make better benefits simple.
Boutique Flexibility
Webuild plans around your needs—not a carrier’s quota.
High-Touch Support
Real humans. Real help. Real answers.
Data-Led Strategy
From benchmarking to forecasting, our team brings analytics into every conversation.
HUB Affiliation
As part of HUB International, we offer the scale and stability of one of the largest brokerages in the world.
Mid-Market Mastery
We specialize in employers with 50–500 employees—no cookie-cutter solutions here.
Speed with Substance
Fast turnarounds. Clear insights. Decisions backed by data, not delays.
Part 2: Your Plan, Your Way— Strategic Features That Solve Real Problems
Self-funding isn’t just flexible—it’s strategic. In this section, we explore the building blocks of a smarter plan: customizable networks, cost-containment tools, carve-outs, wellness programs, and more. Each feature is designed to solve real-world challenges like high renewals, poor member experience, and lack of data. With Fox Everett, your plan is built around your goals, not someone else’s bottom line.
Pharmacy Benefits Management (PBM)
Prescription costs continue to skyrocket, and employers are often left in the dark about pricing structures, rebates, and markups. Without transparency, it’s difficult to know where your money is going or how to control drug spend. Fox Everett partners with transparent, pass-through PBMs that eliminate hidden costs and provide full visibility into pricing, rebate arrangements, and formulary choices—giving you control and savings.
Key Advantages
Lower drug spend (up to 20–30%)
Open, auditable contracts
Real-time member support tools
Utilization and trend reporting
PPO Network Optimization
Many employers rely on legacy PPO networks that deliver limited provider access and inflated “discounts,” often leading to surprise billing and poor value. Fox Everett works with you to evaluate and select networks based on performance, flexibility, and actual value—not brandname. From narrow networks to tiered structures or reference-based alternatives, we help you build a smarter network strategy tailored to your goals.
Key Advantages
Customized network strategy
Expanded access or higher value (your choice)
Contract visibility and flexibility
Ability to tier network options to drive smarter utilization
Reinsurance Marketing & Placement
The threat of high-cost, catastrophic claims keeps many employers up at night, especially if they’re stuck with one-size-fits-allstop-loss contracts. Fox Everett removes the guesswork by marketing your case to a wide pool of underwriters and negotiating terms that reflect your specific risk profile. We ensure you’re covered, competitively priced, and protected from financial disruption.
Key Advantages
Competitive premiums
Tailored contract provisions (e.g., aggregating specific claims)
Laser risk evaluation support
Claims projection modeling to protect your bottom line
Captive Solutions
Self-funding can be risky for smaller employers who lack the scale to absorb claim fluctuations. Fox Everett gives you strength in numbers by connecting you to group captives—risk-sharing alliances of like-minded companies—so you gain the flexibility of self-funding with the safety of shared resources.
Key Advantages
Reduced volatility
Better stop-loss rates
Peer benchmarking and collaboration
Shared administrative resources
COBRA & Section 125 Support
Managing COBRA notices, pre-tax benefits, and compliance reporting can bog down HR teams and introduce serious compliance risks. Fox Everett takes the pressure off by handling all aspects of COBRA andSection 125 administration—from notifications and coverage tracking to seamless integrations and annual filings.
Key Advantages
Fully outsourced COBRA and 125 plan admin
IRS & DOL compliance peace of mind
No missed deadlines or messy record keeping
Seamless enrollment integrations
Part 3: Advanced Features, Real-World Impact, and FAQs
Fox Everett empowers employers to go beyond the basics—combining plan customization with predictive insights, member engagement tools, and ongoing optimization. Here are additional ways we help you stay ahead:
Custom Plan Design
Many employers are stuck with cookie-cutter benefit plans that don’t reflect the specific needs or culture of their organization. These rigid designs limit flexibility and leave both employers and employees underserved. Fox Everett helps employers escape the limitations of carrier templates by designing fully customized plans. Whether you want lower deductibles, richer benefits, or a telehealth first experience, our team helps you create a benefits package that aligns with your values and goals.
Key Advantages
Tailored co-pays, deductibles, and contribution levels
Integrated wellness programs
Lifestyle incentives and disease management
No longer locked into carrier templates
Claims Data Analytics & Reporting
Many companies lack the insight and tools to understand what’s driving their healthcare spend, making it nearly impossible to plan ahead or reduce costs effectively. Fox Everett empowers employers with real-time claims dashboards, trend analysis, and benchmarking reports. These tools allow you to uncover cost drivers, compare performance to industry peers, and take proactive steps to manage risk—all backed by strategic guidance.
Key Advantages
Transparency into claims drivers
Benchmarking by industry and size
Proactive planning with cost forecasting
Mid-year reporting and strategic plan tweaks
HR & Member Advocacy
HR teams are overwhelmed and employees often face a maze of confusing benefits questions without support. The result is frustration, disengagement, and unnecessary administrative burden. Fox Everett provides direct, concierge-level support to both HR and plan members. From benefit guidance to complex claims navigation, our U.S.-based service team acts as an extension of your organization—resolving issues quickly and compassionately.
Key Advantages
U.S.-based service team with named reps
No more 1-800 black holes
Education tools for employees
Direct escalation channel for HR teams
Regulatory Compliance & Fiduciary Protection
Navigating regulations like ERISA, ACA, HIPAA, andIRS guidelines is a full-time job—and getting it wrong can lead to costly penalties. Most internal teams simply don’t have the bandwidth or expertise tostay current. Fox Everett keeps you protected by proactively managing compliance and documentation. We monitor legislative changes, support fiduciarybest practices, and help you maintain a defensible, compliant benefits program year-round.
Key Advantages
Full support for ACA reporting and ERISA docs
HIPAA compliance audits and templates
Fiduciary best practices (and documentation!)
Real-time alerts on rule changes and legal updates
Your Questions Answered.
This FAQ provides clear answers to common questions about the Self-Funded GAP Plan, covering eligibility, coverage, claims, and benefits of enrollment. Explore the questions below to understand how it works and how it can meet your healthcare needs.
Yes. Employers with as few as 50 enrolled employees can successfully self-fund when paired with strategic tools like group captives, level-funding models, and robust stop-loss insurance. The key is partnering with experts like Fox Everett who understand how to structure risk. Our team designs scalable, flexible solutions that remove volatility and make self-funding not only accessible but advantageous.
You’re protected. That’s the purpose of stop-loss insurance. When you self-fund, you set an attachment point—say $50,000—and anything beyond that is covered by the stop-loss carrier. We help you choose the right contract, review historical claims, and structure coverage with confidence. Catastrophic claims don’t break the bank—they’re anticipated, forecasted, and insured.
No—in fact, it usually reduces workload. Fox Everett provides dedicated member advocacy, real-time support tools, and integrated admin systems to reduce friction. HR doesn’t have to chase vendors or answer technical plan questions.We act as your HR partner, not just your broker. The result is faster answers, fewer escalations, and happier teams on both sides.
Yes.Self-funded plans are governed federally under ERISA, which means you’re notsubject to many state-specific insurance mandates. This often simplifiescompliance and gives you more control. It also allows for consistent plandesign across states if you operate in multiple locations. We guide you throughevery detail, ensuring your plan remains compliant at both state and federallevels.
We provide monthly and quarterly reporting dashboards, key performance indicators (KPIs), and trend analysis to help you understand plan efficiency, cost drivers, and utilization. You’ll also get benchmark comparisons against similar employers so you can evaluate how your plan stacks up. These insights allow for mid-year adjustments, not just end-of-year surprises.
Still have questions?
We’re here to help. Whether you’re exploring self-funding for the first time or just want clarity on your current plan, our team is ready to provide clear answers, tailored insights, and honest guidance—no pressure, just partnership.