Sales & Renewal Kit for Level Funded Plans

BBF is a level funded product – combining characteristics of self-funded plans, (as an underwritten, ASO product) and fully insured plans (offering predictable rates and financial protection).

Level funded rates are made up of three parts:

1. administrative costs – such as claims administration, commissions, network access, etc.

2. projected claims funding - what BCBSTX expects group claims to be during the contract term

3. stop-loss coverage – financial protection if claims are higher than expected

Eligibility is based on:

• ERISA qualifying small group
• 12-months of previous coverage
• Good financial standing, no history of delinquencies
• In 2025: minimum 10 enrolled employees (or 75% participation, whichever is greater) up to 50 employees
• NEW FOR 2026: minimum 5 enrolled employees (or 75% participation, whichever is greater) up to 50 employees
• Employer contribution of 50%+ toward the lowest-cost, employee only plan
• At least 75% employee participation, minus valid waivers

Blue Balance Funded contracts are 12 months.

BBF is an underwritten product. This means that we consider the health of the group’s employees when determining the rate. Fully insured plans, under the Affordable Care Act (ACA), offer a fixed premium based only on age and zip codes.

In addition, because BBF is a level funded product, it is not required to include mandated benefits like pediatric dental or vision coverage (which must be included in fully insured / ACA plans).

Think of it as forecasting – but not for weather, this is forecasting for claims. Through years of experience, we can accurately forecast claims based on the group’s characteristics and statistical data.

But, like the weather – sometimes the unexpected can happen. If one, or more, employees’ claims exceed the claims forecast, stop loss coverage continues to offer protection and the group will not be financially responsible for those claims.

BCBSTX pays those unexpected claims as part of the stop loss protection. The group is NOT responsible for those costs and the group’s bill remains stable.

Good years can happen and if claims are less than expected, the group may be eligible for a surplus settlement, provided as a credit for half of the savings. 

For example, let’s say a group’s claims were $200 less than expected for the year. The group may be eligible for a $100 credit toward their next year’s BBF bill. 

NEW FOR 2026: Surpluses for group contracts effective in 2026 are available only if the group remains covered through BBF. If they cancel coverage or move to a fully insured plan, they are not eligible for a surplus.

When a group moves to BBF, BCBSTX forecasts what the group’s expected claims costs are for the year. But, we all know that the unexpected can happen and can cost a lot. That’s why stop-loss protection exists.

Stop-loss begins where claims funding ends and provides two-levels of protection:

1.   Individual, set at $25,000 per person
2.   Aggregate, set at 110% of projected claims for the entire group

If one, or both, of these stop loss levels are met, BCBSTX is financially responsible for those claims dollars – not the group.

BBF is level funded and is not a fully insured product. This means that it isn’t subject to the same regulatory requirements as our fully insured plans. For example, BBF does not include Pediatric Dental or Vision benefits.

BBF plans are similar to plans offered today in our Mid Market (51-150) segment.

Visit the SBC Tool here .

We require proof of business documentation. The most recent TWC report meets this requirement. If the TWC is unavailable, meet this requirement by submitting ONE of the numbered items below as proof of business.

1. Copy of the employer’s Partnership Agreement.  This can include, but is not limited, to

• General Partnership (GP),
• Limited Partnership (LP), and
• Limited Liability Partnership (LLP)

2. Copy of the most recent Form 1065 Schedule K-1 (for each partner)

3. SS4 Form (IRS acknowledgment letter)

4. All the pages of the State Filed Proof of Business document:

• Articles of Incorporation
• Articles of Organization
• Certificate of Organization
• Certificate of Limited Partnership
• Limited Liability Company Organizational
• Certificate of Franchise

5. Documents with Texas State Seal

6. State Filed Doing Business As (DBA)/Assumed Name documents

We require proof of wages documentation. The most recent TWC report meets this requirement. If the TWC is unavailable, meet this requirement by submitting THREE rolling months of payroll. The payroll report must include:

• Group Name
• Employer Identification Number

You can submit W-4 forms for new hires with less than 3 months of payroll.

Employees not listed on the TWC, or if the TWC is unavailable, should be submitted through the Texas Supplemental Employment Verification (TSEV) at the time of enrollment.

Groups may offer up to 3 BBF plans.

No, only composite rates are available for BBF plans.

BBF has the same networks as small group, fully insured/ACA plans - Blue Choice PPO and Blue Advantage HMO.

BBF uses the Performance Drug List formulary.

Yes, but dental plans are fully insured. Groups may select composite OR age rates for dental plans.

Yes, vision plans are available for enrollment.

No, state continuation is not available.

PCORI fees are the responsibility of the group. BCBSTX does not currently assist BBF groups with PCORI fee determinations or submissions.

No, 1095 forms are the responsibility of the group.

No, invitro benefits are not available.

A surplus is based on a simple question – were the group’s claims more, or less, than the forecasted claims funding?

If they were “more”, then the group does not qualify for a surplus. If they were “less”, then the group could qualify for half of the surplus amount, if they remain covered under a BBF plan.

A run-out period is the time immediately following the end of a group’s contract when BCBSTX continues to pay claims incurred while the group was covered through a BBF plan.

Example: if a group’s BBF contract ends on December 31 but a member sees a doctor on December 19 – that doctor may not submit the claim for processing until January 21. BCBSTX still covers that claim because it happened during the contract period and was received during the run-out period.

For 2025 group contracts the run-out period is an additional 12 months after the contract ends.

NEW IN 2026: The run-out period is now 60 months after the contract ends.

If a group leaves their BBF plan before the contract ends, the run-out period still applies and will cover those claims - as long as the claims were incurred while the group was still active.

For 2025 effective dates, a group must be a small group employer with at least 10 enrolled employees and a maximum of 50 eligible employees.

NEW FOR 2026: For 2026 effective dates, a group must be a small group employer with at least 5 enrolled employees and a maximum of 50 eligible employees.

Small groups are determined based upon the average number of employees (full-time, part-time, seasonal, etc.) that were employed on business days during the prior calendar year from the effective date of coverage. For example, if your client wants a BBF effective date of February, 2026, their average employee count would be based on the 2025 calendar year. 

Only deductible credits are allowed for new-to-Blue, BBF groups.

No, BBF plans are only available on first of the month effective dates.

Yes, we recognize valid waivers and exclude them from the group participation calculation.

The standard commission is set at $30 PEPM, but a broker can negotiate their commission. BCBSTX offers a commission range of $20 to $80, available in $5 increments. 

Please make sure the correct commission is entered prior to sharing the BBF quote with your client.

Yes, the group must contribute at least 50% of the employee only coverage of the lowest-cost plan offered.

For 2025: The group must enroll a minimum of 10 employees or 75% of eligible employees (whichever is greater).

NEW FOR 2026: The group must enroll a minimum of 5 employees or 75% of eligible employees (whichever is greater).

No, a group must have at least 12 months of prior group coverage to receive a BBF quote.

To qualify for a BBF quote, a group should have good financial history, free of any bankruptcy proceedings for at least 12-months.

No, retiree coverage is not available.

Yes, we will allow a maximum of 10% of eligible employees to be on COBRA.

For 2025: Login to eSales through your Blue Access for Producers page. Select BBF as the requested quote and follow the prompts. You’ll also need to submit the BBF RFP Form Attachment.

NEW FOR 2026: Quote requests must be submitted at least 20 calendar days prior to the requested effective date. Login to eSales through your Blue Access for Producers page. Select “BBF” as the requested quote and follow the prompts. The BBF RFP Form will now be filled out digitally within the application (no attachment required).

In 2025: Login to eSales and your search for your quote number. Click “Start Enrollment” and follow the prompts. You’ll need to upload the following documents:

• Benefit Program Application
• Administrative Services Agreement
• Stop Loss Application
• Stop Loss Policy
• Standard Business Associate Agreement
• TWC Report (from the most recent quarter)
  • For employees not on the TWC Report, provide the Texas Supplemental Form
• EGI Form
• Enrollment Spreadsheet

NEW FOR 2026: Login to eSales and search for your quote number. Click “Start Enrollment”. Follow the prompts to complete all documents digitally. Information originally entered from the quote will automatically pre-populate some of the enrollment tool fields. Once the enrollment has been approved, documents will be sent out via Docusign for Broker and Group signatures.

You will need to upload the TWC Report from the most recent quarter. For employees not on the TWC Report, please provide the Texas Supplemental Form.

In 2025: BBF enrollments must be submitted by the effective date. This will cause group benefits to be delayed and ID cards will not be available to members on the day their coverage is effective. BCBSTX cannot escalate BBF submission processing.

NEW FOR 2026: BBF enrollments must be submitted at least 12 days prior to the effective date. This helps to ensure that members have access to ID cards and benefits as close to their effective date, as possible.

Yes, for existing BCBSTX groups moving from fully insured/ACA to BBF, deductible and out-of-pocket credits are allowed.

No, BBF is sold as a 12-month contract. Mid-year changes are not allowed.

No, anniversary date changes are not allowed. 

Existing groups must submit their BBF paperwork at least 30 days prior to the renewal date.

If an existing, fully insured / ACA group qualifies for BBF, a proposal will be available with their fully insured renewal. The proposal will only be visible on Blue Access for Producers – the group will not see the proposal on Blue Access for Employers. This allows brokers to make commission changes prior to showing the proposal to their client.

The account number and member IDs stay the same, but the group number will change.

BBF groups benefit from our Blue Insight reporting, available in Blue Access for Employers. Information from these reports can help identify overall group trends for and understanding where health care dollars are spent. 

No, BBF bills are only available through the Blue Access for Employer portal.

No, BBF bills are only available through the Blue Access for Employer portal.If a BBF group is 30 days past their payment due date, the group will be cancelled and cannot be reinstated. They will need to move to a fully insured plan.

If the group has set up auto pay (highly recommended), drafting happens around the 15th of each month.

While not recommended, we can accept checks. Payment deadlines are strictly enforced, and a group will be cancelled if payment is not received within 30 days of the requested due date. Groups are highly encouraged to setup auto payments through Blue Access for Employers.