Definition

The ratio of premium dollars spent on member medical care vs. admin and profit. ACA requires fully insured plans to spend at least 80% (small group / individual) or 85% (large group) on medical care or rebate the difference.

Related in funding & risk

Fully insured

A funding arrangement where the employer pays a fixed monthly premium to a carrier, and the carrier bears all claims risk.

Self-funded

A funding arrangement where the employer pays claims directly out of cash flow (often through a TPA), bears the claims risk, and typically buys stop-loss insurance to cap downside.

Level-funded

A self-funded variant marketed mostly to small/midsize employers.

Stop-loss

Insurance that caps the employer's claims exposure on a self-funded plan.

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SIC, enrolled lives, renewal month, current carrier — every term in this glossary corresponds to a field Velora's outbound engine actually uses for targeting, segmentation, and cadence selection.

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