I have a special needs child. My child is autistic and requires hours of therapy each week: ABA, OT, Speech, etc.

I have always worked at a large well-known company with excellent medical and health-care benefits that have consistently paid for the majority of my child's therapies. To put it in perspective - they have paid about about $80,000 to health care providers this year alone for my child. I consider myself fortunate to have an employer provide this.

I have been hesitant to explore a job change outside of my current company, because it requires broaching the benefits conversation with a potential employer.

Several years back I explored a job with a very small garage startup. We had an open conversation about my child's needs. They had a small health care package and were open to the idea of augmenting what the plan could cover. When they heard the numbers I quoted them for services, they said they had to back away.

Another, much larger and well known company offered me a job. When I told the internal recruiter making the offer about my situation, they put me in touch with their benefits department. The benefits person I spoke with at the time was like, "yeah, I think we cover all that." Perhaps I didn't ask the question right, or they didn't know the specifics. But I exited that call with only a vague understanding of what they covered. I think the most I got was the brochure explaining deductibles and plans, but nothing specific to facility and service codes actually covered. I had declined that job for other reasons.

Fast forward to today. I'm exploring another job opportunity with an established, but small company via an independent recruiter. On site interview is being scheduled soon. The recruiter has been helpful at brokering the conversation with the company's benefits person ahead of time. They have confirmed coverage for some specific providers and services we use. There's a few more providers I need to inquire about, but it's looking more positive. I told the recruiter I would be understandable if they couldn't match my current employer's coverage 100% - so long as I knew precisely what those differences were.

I have two sets of questions.

Who ultimately pays for health care? I'm probably naive for asking, but I honestly don't know. Do employers have a package deal for medical benefits and let the health care company (e.g. Premera, Cigna, Aetna) assume all the risk? Or does this result in higher premiums charged back from the health care company to the employer? Or is the employer actually paying the majority of this? Knowing how my family's health care costs impacts the bottom line of the company - or at least how they perceive that cost - may frame a salary and benefits negotiation later on.

How to confirm all this in a job offer? Ultimately, what I want to avoid is starting work at a new company and finding out that there is a misunderstanding about coverage, deductibles, or specific services covered for my child. What's the most appropriate way to get confirmation on all medical services needed by my family without the employer wanting to rescind the offer because I'm going to cost too much? What's the right way to ask?

I'm in the United States where health care is what it is.

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    Not an answer to your direct question, but If your child is school age or younger, you should investigate services from your local public school system in addition to your company's healthcare. I believe under IDEA ( Individuals with Disabilities Education Improvement Act) the school system should be providing services for your child. This could lessen what you need from your employer. – cdkMoose Dec 11 '19 at 22:25

You asked,

Who ultimately pays for health care?

In the US, it's the payor for your plan that pays the providers for the claims they make. That's a bit of a circuitous answer, but it's essentially the truth. In a true commercial health insurance plan (i.e. a product from United Healthcare, etc) the insurer is the payor. The plan will have members from many employers, all paying premiums, and the plan collects those premiums into a fund to pay claims. On the other hand, some employers choose to be self-funded, which essentially means they provide funds into an account which is used for paying claims, and the plan is run by a third party administrator - the third party admin basically functions similarly to a commercial plan, but they're paying out of the employer's bank account instead of their own. Employers who self-fund may just pay the entire fund themselves, but more commonly, they may collect a premium equivalent from their employees as part of the funding. In either case, the payments are made from an account that is funded by or on behalf of the people in the plan. And - importantly - in either case, the employer is not (typically) involved in actual processing, payment, or decision making about claims. Instead, they select a plan and/or design the benefits options they want to provide, and then someone else runs it. Hence, employers are not typically experts on nuance around exactly how claims will pay for different types of medical needs, although they usually will have a general idea of what's covered for mainstream needs.

There are many additional layers, which may go out of the scope of this question. Most commercial and self funded insurance plans include additional funding mechanisms, such as reinsurance and stop-loss. These are essentially insurance for the insurance plan - they cover cases where single people in the plan have extremely large claims, in order to protect the plan itself from having to pay beyond their funding.

And, of course, there are many government-funded or government-subsidized plans - which essentially means it's us taxpayers that fund the plan. But since you have mentioned employer-provided health insurance, that is likely outside the scope of your question.

Ultimately though, your employer likely won't have any specific or direct financial impact as a result of your claims - even if they are self funded. Their plan will be underwritten and designed to accommodate paying for the benefits it provides.

You also asked,

How to confirm all this in a job offer?

This is an easier question. Get the plan documents from the potential employer. Just ask for the summary of benefits and any other documentation they have. You should not need to explain to anyone at the employer what your individual needs are, and giving such an explanation may just create drama. Instead, get the documents and read them yourself. Compare the claims you have typically submitted in the past (or those which providers have submitted) to the benefits in the plan. If you can't determine a clear answer yourself, contact the plan, not the employer. Ultimately, it's the payor (the plan or the third party admin running the plan) who adjudicates claims. A benefits clerk at an employer will almost certainly not be an expert on specific questions about specific claims, so don't even ask them. Go right to the source - call the people who will actually be processing your claims.

If you still don't get a straight answer, consider asking your providers. If you have a regular provider you use for specific services, have a conversation with their billing staff about how their claims are billed and how they would be handled based on the plan documentation you have. Billing staff may even be able to give you a literal answer because they've dealt with that insurance plan before. Or, they may be willing to call the plan and discuss. It's in their best interest to get a straight answer to this question, so use their help to get the answer. Billing staff want you to be enrolled in a plan that will cover their services.

Finally, it's important to be careful with requests or expectations to have an employer treat you differently than other employees (i.e. pay for health services which aren't covered by their health benefits). While this sort of request may seem innocuous on the surface (shouldn't the employer be able to spend money if they want to?), many employers will be highly reluctant to do so, since providing drastically different health benefits to a specific employee runs the risk of conflicting with regulatory requirements their existing plan is subject to. And, doing so also sets a dangerous and expensive precedent - what happens if other employees come forward and want specific coverage? Plus, this sort of arrangement would mean a direct financial impact to the employer - they wouldn't be able to pay for it out of their current insurance fund and they won't be able to take advantage of stop loss or other protective measures built in to their plan. Further, it would put them in the position of having to adjudicate the claims themselves, against whatever contract they offered you, which again exposes them to regulations and oversight which they probably don't want to get involved in. Ultimately, an employer may theoretically agree to compensate you for your needs outside of their regular health benefit, but the chances are slim enough that it's better to just focus on understanding the default benefits offered in their insurance plan, and shopping for an employer with benefits that meet your needs.

I am editing my answer after re-reading your question a few times, to address a concern you seem to have, based on these questions/statements you made:


Even for a self funded plan, the cost is (at best) only indirectly impacting the employer. Self funded plans are designed and regulated in a way that effectively prevents a single high-cost person from financially impacting the employer. And if the plan is not self funded (i.e. it's a commercial plan), the link is even more indirect, since the risk is distributed across the plan's entire book of business.

Further, it would be illegal for your employer to make employment or compensation decisions based on your medical needs, regardless of whether or not your needs had a financial impact for them. They can't deny a raise, fire you, or change your benefits simply because you had a lot of claims.

And - to further put your mind at rest, speaking as someone who has spent a significant portion of my career doing plan configuration and data analysis work for one of the largest third party administrators in the country, I can tell you that while $80,000 of claims in a year may seem like a lot to you, it is likely far from being significant the plan. There are almost certainly other people on the plan with vastly more expensive needs than your child. Someone on expensive chemotherapy or other specialized treatments may be racking up that much in costs every week (or even one single treatment) much less a whole year. Your child's costs may put him in the top 5% or 10% of claimants, but the top 1% are likely at least two or three orders of magnitude more expensive. In fact, $80,000 in a year may not even be enough to kick in the plan's stop loss or reinsurance. It is, literally, under the radar. So don't get hung up on potentially impacting your employer's finances.


See above - and as a TL;DR summary, since this answer is a wall of text: just ask for the benefits paperwork, check to see if your needs are covered, and then direct any questions related to specific coverage for specific healthcare needs to the plan administrator.

The employer doesn't need to know your needs and likely isn't the best source of detailed information, as explained above. Effectively, if you called your employer and asked their benefits person a bunch of detailed questions, the likely outcome is that they would just call the plan themselves, anyways.

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    This is a terrific answer. Bottom line for the OP- generally speaking, it will most likely be more clear if the employer has a commercial insurance package vs. being self-insured. But the OP will need to do the investigation into "What and how does BlueThis and USThat cover?" – Damila Dec 11 '19 at 15:27
  • Thanks for the compliment. Although I would clarify - self funded vs commercial shouldn't impact whether or not the answer is easy to get. In both cases, the payor is required to provide descriptions of the benefits in standard, (relatively) easy-to-read formats - the documentation that describes the specific benefits is tightly regulated and audited in either case. And in both cases, there will be a toll free number you can call to talk to someone actually involved in adjudicating claims, which is (almost always) the best way to know what is actually covered. – dwizum Dec 11 '19 at 15:31
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    Good to know. Thanks. – Damila Dec 11 '19 at 15:43
  • "your employer likely won't have any specific or direct financial impact as a result of your claims", for a small company this may not be true, this could drive the net claims experience up and cause the insurer to make a significant increase in premium costs. – cdkMoose Dec 11 '19 at 22:25
  • @cdkMoose - That really depends on factors in the plan design and the covered population that are probably well beyond the scope here. Stoploss basically exists such that a single individual can't ruin the cost of the plan. You really need an entire population to have unusually high costs in order for premiums to shift, which arguably isn't the case here. And at any rate, the OP's 80K in claims is almost certainly not even a tiny drop in the bucket in terms of what the plan is paying out in a year. – dwizum Dec 12 '19 at 13:25

Who ultimately pays for health care?

You need not bother about this much. There can be two scenarios:

  • If the coverage is there in the company policy: If the amount which will be needed is covered by the overall / generic organization policies, then the company usually need not pay anything extra to the insurance company, it'll be considered the same as any other employee

  • The coverage (as per your expectation) is extended to you as an exception: In this case, if the amount you expect is not covered by the generic policy, and the organization is extending the amount for you as an exception (through a special clause, or from a specific corporate fund), you are still entitled for the benefits. Ultimately the company will be sponsoring this, one way or the other.

How to confirm all this in a job offer?

You have a specific need, and you need to ensure that those needs are met before you can accept the offer. There are two ways:

  • Either they provide you with a written confirmation that the clauses / coverage you are looking for is actually present in company policy and you'll get what you expected to get (at least up to a certain amount).
  • Or, they add a specific clause in your employment agreement / amend an exceptional clause which ensures you the coverage you want / expect.

Given that you are rather heavily dependent on the company-provided healthcare, you need to ensure the majority of it it taken care of before you leave the current organization. If you need, you can ask for the reference of third-party organization catering the insurance needs and processing the claims and check with them for even more details.

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