About This Worksheet
Compare self-funded and fully insured health plan options for your organization with cost and risk analysis.
This worksheet helps you organize and calculate the key information for self funded fully insured comparison. Fill in each section carefully. Use the calculation areas to verify your numbers before transferring them to the official form.
How to Complete This Worksheet
- Print this worksheet or use it on screen.
- Complete each section in order.
- Use a calculator for all math. Do not estimate.
- Double-check every calculation before moving to the next section.
- Transfer final figures to your official form when complete.
- Keep this worksheet with your records.
Self Funded Fully Tracking
Record your data for self funded fully insured comparison below.
Enter the relevant figure for self. Use official records.
Enter the relevant figure for funded. Use official records.
Enter the relevant figure for fully. Use official records.
Enter the relevant figure for insured. Use official records.
Enter the relevant figure for comparison. Use official records.
Enter the relevant figure for worksheet. Use official records.
Your Information
Enter your details as they appear on your official documents.
As it appears on your government ID.
Today's date, MM/DD/YYYY.
From prior self funded fully insured comparison filings. Write N/A if none.
Additional Notes
Record any other information relevant to your self funded fully insured comparison calculations.
Verification
Before transferring figures to your official form, confirm:
- All figures are accurate and match your source documents.
- All calculations have been double-checked with a calculator.
- Names and dates match your official identification.
- Information is consistent with requirements for self funded fully insured comparison.