How Self-Funded Rates Are Built in Plansight

Every self-funded medical rate in Plansight comes from one equation:

Rate = Fixed Costs + Claims Cost

Fixed Costs are everything the group pays regardless of claim activity. Claims Cost is what the group expects to spend on actual medical claims. Add them together and you have the per-employee-per-month rate for each tier.

What Goes Into Fixed Costs

Fixed Costs are the components that don't move with claim volume. Plansight pulls these from the quotes you've already attached to the plan bundle:

Admin / TPA fees — what the third-party administrator charges to run the plan
Specific Stop-Loss (ISL) premium — protects against a single high claimant
Aggregate Stop-Loss (ASL) premium — protects against the group as a whole running over
Organ Transplant premium — only applies when the carrier carves transplant coverage out separately

Add those four components per tier and you have Fixed Costs.

How Plansight Computes the Claims Cost

Plansight derives Claims Cost from the underwriter's aggregate (AG) factors. Two views are available:

Expected — Plansight divides the AG factors by the corridor (typically 1.20–1.25). This is the underwriter's expected claims cost under normal conditions.
Maximum — Plansight uses the raw AG factors with no corridor applied. This is the worst-case claims cost the aggregate stop-loss would tolerate before kicking in.

Add either Claims Cost figure to Fixed Costs and you get the rate for that view.

Three Rate Structures

A self-funded plan uses one of three rate structures at a time. These are mutually exclusive — pick the one that matches how you want the rate set.

Composite — the default. Plansight computes the rate using composite stop-loss and admin inputs.
Age Banded — Plansight computes the rate using age-banded factors so per-tier rates reflect the group's actual age mix.
Budget Rate — you type the rate per tier directly, and Plansight derives the implied Claims Cost.

Setting a Budget Rate

Sometimes you have a target — typically a fully-insured equivalent — and you want to work backward from it rather than let the system compute. Select Budget Rate on the side-by-side, type your per-tier rate for each plan option, and Plansight back-solves:

Claims Cost = Budget Rate − Fixed Costs

Same equation, rearranged. You set the rate; Plansight tells you what claims cost it implies.

Budget Rate is plan-group synced. Selecting it on one plan option applies it to all options in that plan group, and the modeler's rate controls lock so the side-by-side stays the source of truth.

A Worked Example — Employee-Only Tier

Starting with Fixed Costs:

| Component | Amount | |---|---| | Admin / TPA | $95.00 | | Specific Stop-Loss (ISL) | $85.00 | | Aggregate Stop-Loss (ASL) | $12.00 | | Organ Transplant Premium | $8.00 | | Fixed Costs Total | $200.00 |

If the underwriter's AG factor for Employee-Only is $1,000 and the corridor is 1.25:

Expected Rate = $200 + ($1,000 ÷ 1.25) = $1,000.00
Maximum Rate = $200 + $1,000 = $1,200.00

If you instead select Budget Rate and type $1,050:

Derived Claims Cost = $1,050 − $200 = $850.00

Plansight runs the same math across every tier and every plan option in the plan group.

Where do the Fixed Cost inputs come from? Plansight pulls them from the admin, PBM, and stop-loss quotes you've already attached to the plan bundle in the medical plan editor.
What is the corridor and where does it come from? The corridor is a factor — typically 1.20 to 1.25 — that the underwriter builds into the AG factors to account for claims variance. It's entered as part of the stop-loss quote inputs.
What's the difference between Expected and Maximum rates? Expected divides the AG factor by the corridor to show the underwriter's anticipated claims cost. Maximum uses the raw AG factor — the ceiling before aggregate stop-loss kicks in.
If I switch to Budget Rate, does it affect all plan options? Yes — Budget Rate is plan-group synced. Selecting it on one option applies it across all options in that plan group and locks the modeler's rate controls.
Can I switch between Composite, Age Banded, and Budget Rate? Yes, but only one structure is active at a time. Switching replaces the current rate structure for that plan group.
Where does the self-funded rate appear in the presentation? The computed or budget rate flows into the plan comparison pages as the budgeted rate, and the total medical cost summary breaks out fixed costs, claims costs, and stop-loss costs separately.
How do I build the Fully Insured Equivalents?

scout#stoploss