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
• 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).

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, as long as they remain covered through a BBF plan.  

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. 

If the group cancels BBF coverage (whether voluntarily or involuntarily), they are not eligible for a surplus even if they return to a fully insured BCBSTX plan.

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 coverage begins where claims funding ends and provides two levels of protection:

• Individual, set at $25,000 per person
• 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 claim dollars – not the group.

Visit the Summaries of Benefits & Coverage tool. If you need help, check out our SBC Tool Guide.

We also have policy documents for all BBF Plans.

In general, level funded follows ASO administration practices. Items such as the PCORI Fee and 1095s become the responsibility of the employer. Gag Clause attestation must also be submitted directly by the group. BCBSTX will submit Prescription Drug Data Collection (RxDC) reporting data but BBF groups may be required to confirm our submission and provide additional information.

Because of their ASO status, State Continuation and SB51 do not apply to BBF groups. 

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 Annual 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. Note that Plans 1-10 are available to all group sizes while Plans 11-14 are for groups with 51 or more employees.

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, in vitro fertilization benefits are not available.

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

Bills generate on the first of the month.

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.

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 automatic payments through Blue Access for Employers.

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

Timing for a surplus, also known as the settlement period is based on the group’s contract.

2025 Contracts:

• Group renews in BBF – surplus pays out 90-days after the prior year’s contract ends. It will appear as a credit on a group’s future bill.
• Group leaves BBF – surplus pays out 90-days after the run-out period. In 2025, the run-out period is 12 months after the contract ends.

2026 Contracts:

• Group renews in BBF – surplus pays out 90-days after the prior year’s contract ends. It will appear as a credit on a group’s future bill.
• Group leaves BBF – if a group leaves BBF, due to voluntary or involuntary reasons, the group is longer eligible for a surplus.

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 Scenario:

• A member sees a doctor on Dec. 19, 2025.
• A group’s BBF contract ends on Dec. 31, 2025.
• The doctor submits the claim for processing Jan. 21, 2026.

Result:
BCBSTX still covers that claim because:

• The member saw the doctor during the contract period and
• The claim was received during the run-out period

For 2025 group contracts, the run-out period is 12/24. This represents an additional 12 months run-out period after the contract ends.

For 2026 group contracts, the run-out period is 12/60. This extends the run-out to 48 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. The group will be ineligible for any surplus.

Starting with 2026 effective dates, a group must be recognized as 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 Sept. 1, 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 for new-to-Blue groups is set at $30 PEPM, but a broker can elect to change 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.

Starting with May effective dates, the standard commission set for existing fully insured groups receiving a Blue Balance Funded proposal at renewal is now $45 PEPM. 

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

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 a 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.

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 renewal elections 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.

To move a group from an ACA, fully insured plan to BBF, starting with April renewals, brokers should:

• Login to Request Center via eSales
• Select “Blue Balanced Funded Renewal” under Request Type
• Select “Existing Fully Insured to Blue Balance Funded” under Submission Type

The “Opty ID” found on the client’s BBF proposal is the unique identification number that links the final plan decision, rates and commission to the pre-populated forms that will need to be completed and submitted. For more questions on this process, please contact the Texas Small Group Account Management Team.

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

Find your original quote request in eSales and click on “Enroll”. Follow the prompts to complete all information digitally. Information originally entered from the quote will automatically pre-populate some of the enrollment tool fields. No forms required!

BBF enrollments must be submitted at least 12 days prior to the effective date (and 10 days prior if you are working with a General Agent). This helps to ensure that members have access to ID cards and benefits as close to their effective date as possible.

Get the Eligibility Checklist and Due Dates flyer . 

• Page 1 is the eligibility checklist
• Page 2 lists the quoting and enrollment deadlines for each month’s effective date

No. You have the option to save your enrollment and return to it at a later time, simply by searching the enrollment tool for client. Just remember, that enrollments must be submitted by the applicable due date. 

Review page 2 of the Eligibility Checklist and Due Dates flyer for quoting and enrollment deadlines.

Edits cannot be made to DocuSign documents. If an error is found, the signee should click “Decline” and identify the reason for the decline. The case is returned back to Esales for updates and can then be re-released for signature. Edits can be made once the status is changed to “Enrollment More Info Required”.

Yes, brokers can update email addresses and submit ​requests to resend documents as long as the documents​ are not in our Underwriting or Operations queues and have not already been signed. Once signed, no further​ changes can be made.