David Cook | Self-Funded Health Plans @DCookBenefits

@DrBruggeman Those hospitals know patients will travel for the right place. A self-funded employer can use that on purpose by paying the travel and waiving cost sharing for a bundled price at a center the plan picks. Transplants are the kind of claim that can wreck a small plan.

@CBSNews The biggest mistake I expect this year is people letting last year's plan auto-renew. Premiums are up about 15% on average, subsidies are smaller, and the out-of-pocket max goes to $12,000 for one person. Shop it before it rolls over.

@GOPoversight @RepJamesComer Self-funded employers should pay attention to this one. The audit rules that squeeze independent pharmacies sit inside the same PBM contract your plan signed. Ask your PBM what it recovers from pharmacy audits each year and whether any of that money comes back to your plan.

@mcuban @costplusdrugs In most cases it's the employer, and they never find out. A fully insured group buys the PBM inside the premium and never sees a drug-level claim. A self-funded plan can carve pharmacy out, get the claims, and decide which drugs go through a cost-plus pharmacy instead.

Heads up, Texas. ACA open enrollment starts Nov. 1. If you use an agent on HealthCare.gov, you'll get a code by text, email, or call to approve them. New, moved, switched agents, or paying $30 a month or less? You verify your ID first. Don't ignore that code.

@JahangirAsgha10 One catch for Texans. A state law like that reaches fully insured plans, but ERISA keeps it from reaching self-funded employer plans. A self-funded employer can still write the same rule into its own plan document and credit cash payments toward the deductible.

@Benefitsguynick Agree, Nick. It's also where an employer can see the money most clearly. Pull the top 20 drugs by plan spend, put what the plan paid next to a cost-plus price, and ask the PBM to explain the gap. That one report starts a lot of good conversations.

@mcuban @statnews Self-funded employers should be watching this. One rare disease claim can wreck a small plan's stop-loss renewal or get that member lasered. If Cost Plus can bring down the cost of making one-patient treatments at the Dallas plant, that's real relief for smaller plans.

@txsportsdoc @UHC Worth telling him he can ask for an expedited appeal when a delay seriously affects his ability to function. The plan has 72 hours to decide. And with a $5,000 deductible, a cash quote from a surgery center may cost him less than the deductible would.

KFF's new survey says 71% of covered workers are now in self-funded plans. So for most people with job-based coverage, the employer already writes the rules... which PBM, which network, what the plan covers. If costs keep climbing, the fix starts in that plan document.

A primary care visit is a primary care visit, right? HCCI found one averaged $116 in a physician office and $217 billed as hospital outpatient. Employers, have you ever checked how much of your plan's primary care gets billed the second way?

A lot of employers have never read their broker's compensation disclosure. Under the CAA, your health plan's broker has to disclose direct and indirect pay in writing. Read the indirect part, the bonuses and fees from carriers and vendors. If it's vague or missing, ask why.

Agreed. For a self-funded employer it's also a legal duty. The plan's fiduciaries are supposed to know what the plan pays and to whom, and the CAA bans contract terms that block them from getting their own claims data. Show me what I paid for belongs in every TPA and PBM contract.

Worth knowing both sides. A qualifying life event like marriage, a new baby, or losing other coverage lets you change your election mid-year. And a crowdfunding program isn't insurance... nothing guarantees a big bill gets paid. Know that before you waive a plan your employer helps pay for.

@Benefitsguynick Agree, Nick. Pay the doctor per visit and you get more visits. Pay a flat monthly fee and the doctor finally has time for the stuff that keeps people out of the ER. The employer's job is making DPC the easy path... no copay, and a plan design that actually steers people there.

@ForestParkPharm Employer plans should run this same check. Pull your top generics by plan spend and compare what the plan paid to a cost-plus cash price. If a generic is costing your plan many times the cash price, go read the PBM contract, because that's where the markup lives.

The employer side of this is that hospital prices land straight in the claims a self-funded plan pays. Start by finding out what your plan pays each hospital compared to Medicare. Then contract directly with the ones willing to give you a fair, fixed price, and steer people there.

Texans on Marketplace plans, open every letter and take every call from your insurer this fall. CMS has been dropping people who didn't answer verification requests within 30 days, and getting reinstated can take weeks. A five minute phone call now is a lot easier than that.

Myth: self-funding only makes sense for big employers. Reality: smaller groups do it too, with stop-loss or a captive behind them. What matters more is whether you can stomach a bad claims month and want to see your data. Employers, what's held you back?

@AtlasMD Employers can close that gap without blowing up the plan. Pay the DPC membership and keep the HDHP for the big stuff. It doesn't cost anyone their HSA anymore either. IRS Notice 2026-5 confirms DPC fees up to $150 a month for an individual are HSA-compatible starting this year.