Level-Funded vs Fully Insured Calculator

Model your potential savings with level-funded health coverage — see best-case, worst-case, and expected scenarios side by side

Free • No Login Required • Calibrated to 2026 Market Data

What This Means For You

Level-funded plans are a middle ground between traditional insurance and self-funding. You pay a predictable monthly amount, but if your employees use less health care than expected, you can get money back. It is like traditional insurance with a built-in refund possibility for healthy groups.

This tool compares a level-funded plan against your current fully insured setup. Enter your company details below and you will see whether the potential savings and refund opportunity make this a good fit for your team. It is most useful for small and mid-size groups with steady claims.

Step 1 — Your Group

Group demographics are the single biggest factor in level-funded pricing. Younger, healthier groups see the most savings potential.

Number of Employees ?Full-time employees eligible for health benefits. KFF's 2025 survey found 37% of covered workers at firms with 10 to 199 workers are in level-funded plans. Carrier minimum group sizes vary.Source: KFF 2025 EHBS

State ?State rules on stop-loss for small employers differ: some states set minimum attachment points or restrict sales to small groups. The calculator uses the state's average employer premium (AHRQ MEPS-IC 2025) only to scale the modeled stop-loss premium.Source: NAIC Stop Loss Insurance Model Act; AHRQ MEPS-IC 2025

Average Employee Age 38 ?Average age of covered employees. Level-funded underwriting weights age: younger groups usually get lower rates and stop-loss premiums. The calculator scales expected claims with the CMS federal default age curve (age 21 = 1.000, age 40 = 1.278, age 64 = 3.000), used here as a modeling proxy.Source: CMS federal default age curve

Industry ?Industry affects claims experience and level-funded pricing. Healthcare and construction workers tend to have higher claims. Tech and professional services trend lower. Carriers use SIC/NAICS codes for underwriting. The industry factors in this calculator are modeling assumptions.

% Employee Only 60%

% EE + Spouse 20%

% Family 20%

Step 2 — Current Fully Insured Plan

Enter your current fully insured costs so we can model exactly how a level-funded alternative compares. If you don't have current coverage, use the default as a benchmark.

Current Monthly Premium PEPM ($) ?Per-employee-per-month blended premium across all tiers. The 2025 national average total premium for single coverage was $9,325 a year, about $777 a month (employer + employee share).Source: KFF 2025 Employer Health Benefits Survey

Annual Renewal Increase 10% ?Expected annual increase in your fully insured premiums. For context, the average family premium rose 6% in 2025; your own renewal can differ widely.Source: KFF 2025 Employer Health Benefits Survey

Plan Tier ?ACA metal tiers determine actuarial value — the percentage of average costs the plan covers. Higher tiers mean richer benefits and higher premiums, but also higher expected claims in a level-funded model.Source: CMS Actuarial Value Calculator

Step 3 — Level-Funded Model

These parameters define how your level-funded plan would be structured. The claims ratio, stop-loss attachment, and admin fee determine your monthly cost and risk exposure.

Expected Claims Ratio 70% ?The portion of premium that goes to paying medical claims vs. carrier profit, admin, and reserves. The ACA medical loss ratio rule requires insurers to spend at least 80% of small-group premium (85% in the large-group market) on claims and quality improvement. The default here is a modeling assumption; use the expected-claims figure from a real quote if you have one.Source: 45 CFR Part 158

Stop-Loss Attachment Point ?The per-person annual deductible on your stop-loss policy. Claims above this amount for any individual are covered by the stop-loss carrier. Lower attachment = more protection but higher stop-loss premium. The stop-loss premiums in this calculator are modeling assumptions, not carrier rates.

Admin Fee Estimate 15% ?Third-party administrator (TPA) fees, network access charges, and plan management costs. Includes claims adjudication, reporting, compliance, and customer service. The default is a modeling assumption; use the figure from a real quote.

Level-Funded vs Fully Insured Analysis

Fully Insured

per month total

$0/yr

Level-Funded (Expected)

per month total

$0/yr

Expected Annual Savings with Level-Funded

0% lower than fully insured

Based on expected claims scenario with current group demographics

Level-Funded Monthly Cost Breakdown (PEPM)

Component	PEPM	Monthly Total	% of Total

Scenario Analysis — What Could Happen?

Best Case (Low Claims Year)

Surplus refund potential

Expected (Average Claims)

Typical savings range

Worst Case (High Claims Year)

Stop-loss caps your exposure

Risk Spectrum — Where Does Level-Funded Sit?

Fully Insured
(Lowest Risk) Level-Funded
(Moderate Risk) Self-Funded
(Higher Risk) Full Self-Insured
(Highest Risk)

3-Year Cost Projection

Fully Insured Cost:
Current PEPM x number of employees x 12 months. Projected forward using the annual renewal increase rate.

Level-Funded Breakdown:
- Claims Fund: PEPM x claims ratio x age factor x industry adjustment (your current premium already reflects your state, so no state factor is applied). This is held in a claims account to pay medical expenses.
- Admin Fee: PEPM x admin percentage. Covers TPA fees, network access, compliance, and reporting.
- Stop-Loss Premium: Based on attachment point selected. Lower attachment = higher premium but more protection. Modeled premium for the selected attachment point, adjusted for age and for the state factor. These are assumptions, not carrier rates.
- Total Level-Funded: Claims Fund + Admin Fee + Stop-Loss Premium.

Scenario Modeling:
- Best Case: Actual claims at 55% of expected. Employer receives ~50% of surplus (unused claims fund) as a refund.
- Expected Case: Actual claims match the expected claims fund. No surplus, no shortfall.
- Worst Case: Claims run 130% of expected, but stop-loss (both specific and aggregate) caps total exposure. Maximum cost is capped at claims fund + stop-loss corridor (typically 125% of expected).

State Factor:
The state's 2025 average total single-coverage premium at private-sector employers divided by the U.S. average ($9,025 a year), from AHRQ's Medical Expenditure Panel Survey, Insurance Component (MEPS-IC). Applied only to the modeled stop-loss premium.

Age Factor:
Uses CMS 3:1 age rating curve. Age 21 = 1.0, age 40 = 1.278, age 64 = 3.0. Normalized to the baseline age of 38.

3-Year Projection:
Fully insured trends at the entered renewal rate. Level-funded trends at 75% of the fully insured rate; this is a modeling assumption.

Data Sources: KFF 2025 Employer Health Benefits Survey; AHRQ MEPS-IC 2025 state premiums; CMS federal default age curve; ACA medical loss ratio rule (45 CFR Part 158); NAIC Stop Loss Insurance Model Act. The claims ratio, admin fee, stop-loss premiums, industry factors and scenario percentages are Benefitra modeling assumptions.

How This Calculator Is Built

Published survey data sets the benchmarks; the level-funded cost model uses stated assumptions you can change.

CMS Age Curve

The federal default age rating curve scales expected claims by average age

KFF Employer Survey

2025 national figures on premiums, worker contributions and level-funded plans

AHRQ MEPS-IC

2025 average employer premiums by state, used for the state factor

Stated Assumptions

Claims ratio, admin fee, stop-loss premium and scenario percentages are modeling assumptions you can adjust

Want a Custom Level-Funded Quote?

Get a side-by-side comparison with actual carrier quotes, reviewed by a benefits advisor.

Getting Started — Your Next Steps

Capture your results — take a screenshot or write down the key figures
Compare these estimates against your most recent renewal notice
Bring these numbers to your next conversation with your broker or advisor
Ask about any hidden fees, participation requirements, or waiting periods
Target your next renewal date as the ideal time to make any changes

Common Questions

Is this level funded calculator really free?

Yes, completely free with no strings attached. You do not need to create an account, provide an email address, or speak with anyone. Calculations run in your browser. Benefitra collects information when you submit a form or request a report, and this tool may save what you enter as you work. Analytics cookies are used only with your consent. See our Privacy Policy.

How accurate are these estimates?

The benchmarks are published survey figures, but the level-funded model uses stated assumptions (claims ratio, admin fee, stop-loss premium, scenario percentages), so treat it as a directional estimate. Your actual costs will depend on your specific situation, location, and the providers you work with. We recommend using these numbers as a starting point for getting real quotes.

What should I do with these results?

Use them as a baseline for informed conversations with brokers, PEOs, or insurance providers. Having these numbers before you talk to a salesperson puts you in a much stronger negotiating position and helps you evaluate whether the proposals you receive are competitive.

State figures used by this level-funded calculator

Employer figures are the 2025 average total premium per enrolled employee at private-sector employers that offer coverage, employer and employee shares combined, shown per month (AHRQ MEPS-IC 2025, via KFF State Health Facts). The state factor is the state's single premium divided by the U.S. average ($9,025 a year). The calculator applies it only to the modeled stop-loss premium, because the current premium you enter already reflects your state. The claims ratio, admin fee, stop-loss premiums and scenario percentages are modeling assumptions, not published figures.

Pick a state above, or link straight to one with ?state=TX (any two-letter code).

Small-group size: California, Colorado, New York and Vermont define a small employer as 1 to 100 employees, instead of the federal default of 1 to 50 (CMS state rating table).

Show all 50 states

State	Employer single premium (2025)	Employer family premium (2025)	State factor (single premium / U.S.)
Alabama	$681/mo	$1,963/mo	0.91
Alaska	$886/mo	$2,511/mo	1.18
Arizona	$644/mo	$1,929/mo	0.86
Arkansas	$650/mo	$1,913/mo	0.86
California	$764/mo	$2,255/mo	1.02
Colorado	$735/mo	$2,088/mo	0.98
Connecticut	$832/mo	$2,392/mo	1.11
Delaware	$788/mo	$2,133/mo	1.05
Florida	$743/mo	$2,116/mo	0.99
Georgia	$742/mo	$2,203/mo	0.99
Hawaii	$690/mo	$1,967/mo	0.92
Idaho	$731/mo	$2,163/mo	0.97
Illinois	$810/mo	$2,354/mo	1.08
Indiana	$696/mo	$1,958/mo	0.93
Iowa	$718/mo	$2,098/mo	0.96
Kansas	$721/mo	$2,124/mo	0.96
Kentucky	$745/mo	$2,043/mo	0.99
Louisiana	$734/mo	$2,137/mo	0.98
Maine	$817/mo	$2,176/mo	1.09
Maryland	$730/mo	$2,060/mo	0.97
Massachusetts	$870/mo	$2,468/mo	1.16
Michigan	$686/mo	$1,983/mo	0.91
Minnesota	$716/mo	$2,162/mo	0.95
Mississippi	$634/mo	$1,828/mo	0.84
Missouri	$674/mo	$2,127/mo	0.90
Montana	$742/mo	$1,832/mo	0.99
Nebraska	$742/mo	$2,236/mo	0.99
Nevada	$685/mo	$1,923/mo	0.91
New Hampshire	$792/mo	$2,347/mo	1.05
New Jersey	$812/mo	$2,472/mo	1.08
New Mexico	$787/mo	$2,207/mo	1.05
New York	$909/mo	$2,479/mo	1.21
North Carolina	$718/mo	$2,109/mo	0.95
North Dakota	$776/mo	$2,075/mo	1.03
Ohio	$734/mo	$2,055/mo	0.98
Oklahoma	$677/mo	$2,040/mo	0.90
Oregon	$769/mo	$2,265/mo	1.02
Pennsylvania	$785/mo	$2,219/mo	1.04
Rhode Island	$782/mo	$2,280/mo	1.04
South Carolina	$713/mo	$2,087/mo	0.95
South Dakota	$749/mo	$2,176/mo	1.00
Tennessee	$722/mo	$2,094/mo	0.96
Texas	$712/mo	$2,088/mo	0.95
Utah	$704/mo	$2,094/mo	0.94
Vermont	$834/mo	$2,121/mo	1.11
Virginia	$748/mo	$2,271/mo	0.99
Washington	$726/mo	$2,302/mo	0.97
West Virginia	$740/mo	$2,174/mo	0.98
Wisconsin	$796/mo	$2,276/mo	1.06
Wyoming	$750/mo	$2,257/mo	1.00
United States	$752/mo	$2,190/mo	1.00

State figures used by the level-funded calculator

The level-funded calculator starts from the per-state figures below. Estimates are shown as estimates and are not quotes; confirm details with your carrier, plan administrator or state insurance department.

Alabama figures for the level-funded calculator
Alaska figures for the level-funded calculator
Arizona figures for the level-funded calculator
Arkansas figures for the level-funded calculator
California figures for the level-funded calculator
Colorado figures for the level-funded calculator
Connecticut figures for the level-funded calculator
Delaware figures for the level-funded calculator
Florida figures for the level-funded calculator
Georgia figures for the level-funded calculator
Hawaii figures for the level-funded calculator
Idaho figures for the level-funded calculator
Illinois figures for the level-funded calculator
Indiana figures for the level-funded calculator
Iowa figures for the level-funded calculator
Kansas figures for the level-funded calculator
Kentucky figures for the level-funded calculator
Louisiana figures for the level-funded calculator
Maine figures for the level-funded calculator
Maryland figures for the level-funded calculator
Massachusetts figures for the level-funded calculator
Michigan figures for the level-funded calculator
Minnesota figures for the level-funded calculator
Mississippi figures for the level-funded calculator
Missouri figures for the level-funded calculator
Montana figures for the level-funded calculator
Nebraska figures for the level-funded calculator
Nevada figures for the level-funded calculator
New Hampshire figures for the level-funded calculator
New Jersey figures for the level-funded calculator
New Mexico figures for the level-funded calculator
New York figures for the level-funded calculator
North Carolina figures for the level-funded calculator
North Dakota figures for the level-funded calculator
Ohio figures for the level-funded calculator
Oklahoma figures for the level-funded calculator
Oregon figures for the level-funded calculator
Pennsylvania figures for the level-funded calculator
Rhode Island figures for the level-funded calculator
South Carolina figures for the level-funded calculator
South Dakota figures for the level-funded calculator
Tennessee figures for the level-funded calculator
Texas figures for the level-funded calculator
Utah figures for the level-funded calculator
Vermont figures for the level-funded calculator
Virginia figures for the level-funded calculator
Washington figures for the level-funded calculator
West Virginia figures for the level-funded calculator
Wisconsin figures for the level-funded calculator
Wyoming figures for the level-funded calculator