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What is a “carve-out” in health insurance?

“To sum it up…”

  • A carve-out plan involves one health insurance provider excluding coverage for specific situations or conditions while another carrier provides coverage for these excluded conditions
  • Carve-out plans are mostly preferred by employers because they offer a cost-effective way of providing health insurance for employees
  • Big employers who self-insure their employees have a vast array of carve-out options such as cancer, trauma, cardiac care, neonatal intensive care and organ transplant
  • Before signing up for your employer’s health insurance policy, find out whether it’s a carve-out plan and what risks are excluded if so

If there is one facet of health insurance whose understanding eludes a lot of people, it’s the carve-out health insurance plan. Basically, carve-out plans cobble coverage together via several different carriers. Typically, carve-out plans are offered by employers who self-insure their employees.

Sometimes, carve-out plans are reserved for high ranking company executives, a low-risk subgroup of employees. When this happens, the rest of the company’s employees may be left without necessary health insurance coverage.

In a business setting, carve-out health insurance policies need an able leadership and strong management capable of negotiating appropriate coverage for employees in carved out health insurance plans.

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Carve-Out Plan: Definition


Sometimes, self-insuring employers can isolate specific risks and use a third party vendor to cover them. The third party vendor will assume financial risk and receive a flat fee from the company in exchange for coverage.

This health insurance coverage situation is referred to as carve-out health insurance.

Services Offered via Carve-Out Health Insurance Plans

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Employers, over the past few years, have carved out health insurance plans in several specialty areas. Some of these areas include:

  • High-priced health services such as burn units and organ transplants
  • Visual services
  • Dental services
  • Pharmac.
  • Mental health

A carve-out health care plan will offer care and products that may be considered too costly under a regular group insurance policies at a reduced premium.

A carve-out health insurance plan can provide high quality managed care for partakers with specialty pharmacy requirements, behavioral health challenges and people suffering from chronic illnesses.

Some of the reasons why companies prefer carve-out health insurance plans include:

  • To reduce the costs of providing health insurance for their employees
  • To ensure that employees have consistent access to medical care
  • To provide comprehensive health care options for employees
  • To minimize bureaucracy in the health care department

Paid Curve-Out Plan for Extra Protection


As a patient, you can opt to pay extra for a carve-out plan if deemed fit. The additional coverage will be offered by a third party vendor on top of your standard health insurance coverage.

The carve-out plan will cater for the costs associated with chronic illness, prescription medication, and other forms of specialized products or care. It is a good way to supplement your employer-provided health insurance coverage.

Carve-Out Programs and Businesses

Carve-out programs can help companies reduce the cost of health insurance significantly. With an effective curve-out program, actuaries can provide better expense estimations and offer better case management support.

Catastrophic carve-outs neutralize cost upsurge by removing coverage of certain services from the stop-loss policy.

Advantages of Carve-Out Program for a Business


  • Through carve-out programs, companies can negotiate better drug prices. In a catastrophic case, the cost of drugs is a major expense and a company acting alone can sustain serious financial debts in such a case.
  • Companies are able to follow up with the critical care in transplant cases and ensure administration of appropriate recovery drugs.
  • The company can better predict plan expenses by pulling out volatile areas of care from the health plan and in turn provide a better, more efficient overall health care plans.
  • A carve-out plan provides budget certainty to a self-insuring business by taking less frequent but expensive medical services such as heart transplants and putting them in a fixed cost environment.
  • In the face of the ever high deductibles, carve-out programs offer a chance for expense neutrality to companies offering stop-loss coverage to their employees.
  • Carve-outs can help decentralized global firms and their affiliated companies take charge of their health insurance risk management. Often, carriers are reluctant to cover companies with exposed locations, deeming them as high risks.


  • The business will have to draft multiple pharmacy and medical contracts since you will be dealing with more than one vendor for different products. This can place additional the administrative burden on a business.
  • The company will need to integrate pharmacy and medical accumulators if you choose to combine them. You will have to use company resources to do so.
  • Carve-out plans come with coordination challenges.

Companies’ Guidelines on Using Carve-Outs in Health Insurance


When it comes to providing group health insurance, carve-outs can be useful in risk prediction and management. However, carve-outs should be used in moderation and when most appropriate. Here’s how:

Consider the Risks


A carve-out program will present its own challenges. Be prepared to deal with all the associated risks by putting the correct measures in place. Some of these challenges include:

  • A firm can experience transitional challenges after adopting the approach when dealing with employees’ health insurance
  • Problems with legal recourse and first loss coverage
  • Counterparty peril of any health insurance company
  • Third-party provider’s performance may turn out to be subpar.

Determine if a Carve-out is Right for Your Company

– A carve-out program is right for your business if:

  • Your business views the risk as unacceptable at any cost.
  • The company lacks systems, skills, and human resources to manage the risk effectively.
  • You have bought the services of an outside provider to provide risk management services with efficacy and effectiveness.

Set Realistic Goals


Carve will iron out the process of providing health insurance to your employees. However, expecting carve-outs to reduce the overall risk is unrealistic. Use carve-outs to acquire wider coverage with better T&Cs, lower deductibles, and higher limits instead.

Analyze Costs and Benefits

Before the implementation of a carve-out program, it is imperative to consider the costs that come with risk transfer and risk retention. Review the following factors before you implement the program:

  • Operational costs
  • Economic capital costs
  • Projected losses
  • Insurance and reinsurance costs

As an employee, you will need to be careful when it comes to carve-outs in your employer’s health insurance plans. A carve-out program in your workplace environment could mean difficulties in claim processing resulting in frustration and confusion

It’s  important to understand the policy issued by the employer and how the carve-out program will affect your rates and claim payments. For your employer, a carve-out program will cut costs and increase the business’s profitability.

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  5. https://www.hhs.gov/healthcare/
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