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Can

Healthcare Brokers/Advisors Help Improve Our Healthcare System?

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TABLE OF CONTENTS

JULY 2026 VOL 212

W W W. S I P C O N L I N E . N E T

F E AT U R E S 4

CAN HEALTHCARE BROKERS/ADVISORS HELP IMPROVE OUR HEALTHCARE SYSTEM? Written By Laura Carabello

RETHINKING STOP LOSS

FROM LEVERAGING ADAPTIVE CAPTIVE TO WEEKLY AGGREGATE ACCOMMODATIONS, SELF-INSURED HEALTH PLANS ARE TRYING NOVEL APPROACHES TO EASE THE STING OF A HARDENED MARKET

Written By Bruce Shutan

ARTICLES 36

INNOVATIVE MENTAL HEALTH SOLUTIONS EASE PRESSURES ON ACCESS TO CARE

Written By Laura Carabello

EVOLVING FMLA LAWS – 2026 STATE ROUND-UP

AGENCIES PROPOSE NEW EXCEPTED BENEFIT OPTION FOR FERTILITY TREATMENT Written By Alston & Bird, LLP Health Benefits Practice

MEMBER NEWS

Written By David Ostrowsky

The Self-Insurer (ISSN 10913815) is published monthly by Self-Insurers’ Publishing Corp. (SIPC). Postmaster: Send address changes to The Self-Insurer Editorial and Advertising Office, P.O. Box 1237, Simpsonville, SC 29681, (888) 394-5688 PUBLISHING DIRECTOR Bryan Irland, SENIOR WRITER Bruce Shutan, CONTRIBUTING EDITORS Mike Ferguson, Jennifer Ivy, PRESIDENT/CEO Erica M. Massey, CFO Grace Chen

JULY 2026

F E AT U R E

Can

Healthcare Brokers/Advisors Help Improve Our Healthcare System?

Written By Laura Carabello

hen the doctor asks the patient, “Where does it hurt?” and the ailing patient responds, “It hurts everywhere,” this dialogue could describe a consultation between benefit brokers and self-insured employers regarding pain points for healthcare costs and plan coverage. As the U.S. healthcare system faces a convergence of financial, workforce and policy pressures that have created widespread strain on patients, providers and insurers, benefits brokers are helping employers to blunt the stinging impacts of rising expenditures that continue to outpace wages and inflation. Many of today’s brokers are responding proactively to these stressors, delivering guidance and solutions that balance cost, compliance and member experience as well as relieving administrative burdens. In this environment, and increasing number of healthcare benefits, brokers have evolved from simple "plan shoppers" into strategic consultants who use data, technology and alternative funding models to address the issues. Affordability and cost reduction have captured center stage as a priority for 54% of employers, documented by the 2026 Lockton National Benefits Survey that finds employers are turning to brokers to cast a wider net to find answers. “Good brokers are worth their weight in gold,” shares Christine Cooper, CEO, aequum LLC, who was recently appointed to the Self-Insurance Institute of America's Board of Directors. “They play an integral role in employer and member satisfaction and are a key factor in a successful relationship between the employer, TPA, and other vendors. Serving as the connection between all parties, a skilled broker brings clarity to complexity: translating plan design, benefits options, and administrative processes into language that employers and members can act on. When a broker is engaged, informed, and advocating effectively, the entire benefits ecosystem runs more smoothly and predictably.” 4

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Improve Healthcare System Brokers typically sell insurance products and are compensated by insurer commissions, which limits their ability to act as fully independent advisors, argues George Stiles, President and COO, Planned Administrators, Inc.: “While many brokers assist with enrollment logistics and basic advocacy, their incentives are not aligned to systematically reduce costs or redesign benefits; their goal Christine Cooper is to get the lowest cost administrative rate without considering what is driving plan cost and what can be done to bend the curve.” He explains that consultants, by contrast, are paid directly by employers through flat or PEPM fees and can be part of the solution when aligned with client goals, noting, “Our organization works with firms who are leveraging deep claims analysis to understand cost drivers, design customized benefits, negotiate effectively and provide true advocacy — demonstrating how aligned consultants can materially improve outcomes.” While many brokers find themselves in an enviable position with a full complement of clients, they are generating mixed messages from lawmakers. One large employer group, the ERISA Industry Committee (ERIC), is supporting a bill that could change how some pharmacy benefit managers pay employers' brokers, consultants and advisors. While calling for greater levels of trust, James Gelfand, CEO of ERIC, publicly complimented benefits brokers for providing an incredibly valuable service and bringing the expertise that employers simply don’t have and can’t afford to include in their benefits department.

James Gelfand

Reinforcing the value of benefits brokers, Bruce D. Roffé, President and CEO, H.H.C. Group, explains, “Brokers can either maintain the status quo during annual renewals and by making incremental tweaks or act as system architects who redesign healthcare delivery and financing. Brokers aren’t just intermediaries—they’re

the most underutilized force for fixing healthcare. By realigning incentives, demanding transparency and engineering high-value care ecosystems, brokers can turn a broken system into a performance-driven one.”

Bruce Roffé BENEFITS BROKERS, ADVISORS OR CONSULTANTS – WHAT’S THE DIFFERENCE?

There is a distinction between the three roles, although they all endeavor to serve plan sponsors and HR managers who are focused elsewhere without the time to become experts in insurance policies and employee benefits. For most employers, using an insurance consultant, advisor, or broker will save time and total costs compared to going it alone. April Gill, CCO, Smart Data Solutions, imparts, “Brokers become true advisors when they move beyond market comparisons and apply operational intelligence to benefits strategy. Rising costs, fragmented workflows, and poor data visibility limit impact and make JULY 2026

TPA SUMMIT TPA SUMMIT

Improve Healthcare System this shift essential. With clean, connected, real-time data across claims, enrollment, eligibility and provider interactions, brokers can guide smarter plan design, resolve issues faster and identify cost control opportunities earlier.”

April Gill

From her perspective, open enrollment and member advocacy improve when underlying processes are automated and transparent.

“The future role of brokers is not transactional, but integrated, working alongside TPAs, payers and intelligent platforms to improve efficiency, strengthen employer control, and improve outcomes across the payer ecosystem,” says Gill. HEALTH BENEFITS BROKERS

A health benefits broker serves as an intermediary, matching clients with suitable insurance policies that meet their specific needs and budgetary constraints. Brokers are typically independent agents who focus primarily on selling, renewing and facilitating insurance plans, working with multiple insurance carriers and offering a wide array of options to their clients. They often navigate the increasingly complex web of transparency requirements and federal regulations, ensuring the employer doesn't face stiff penalties for non-compliance. Since modern HR teams are often understaffed and overburdened, brokers act as a technical and regulatory safeguard for compliance management. They are compensated through commissions paid by insurance companies for policies sold. This commission structure may vary depending on the insurer and the type of policy, but it is important to note that brokers do not receive direct payments from their clients. Typically, brokers are motivated to secure policies that satisfy their clients while maximizing their own commissions. However, since they work on a commission basis, there

Barbora P. Howell

may be a perception of bias towards policies that offer higher commissions, although ethical brokers prioritize client needs above all else. Barbora Howell, CEO and CoFounder, TrueClaim attests that brokers can truly act as advisors: “The best brokers absolutely can, but it depends entirely on how they’re compensated and how transparent they are about it. A commission tied to a specific carrier creates a different conversation than a flat consulting fee.” She says the brokers driving real value today behave more like fiduciaries: “They benchmark rates aggressively, model alternative funding arrangements and bring data to the table rather than a pitch. Plan sponsors should ask their broker directly how they get paid and what they’re doing year-round, not just at renewal. The answer tells you whether you have an advisor or a salesperson.” There is consensus across the industry, as Dani Kimlinger, PhD, MHA, SPHR, SHRM-SCP, CEO, Mines & Associates, says that brokers truly act as advisors. “This is where the broker role has never mattered more,” says Kimlinger. “The most effective brokers today are exercising judgment, not just presenting options. Advisory work means helping employers filter signals from noise, make intentional JULY 2026

Improve Healthcare System tradeoffs, and occasionally say, ’this sounds interesting, but may not be right for your workforce because of… xyz.’ In a saturated market, discernment, not “shiny objects,” can make the broker a truly impactful advisor.” Equally important, she points out that brokers hold a unique position of influence, adding, “They are often the only players who can credibly tell carriers and point solutions: if you want to be part of this ecosystem, you need to integrate and play well with others. We’ve seen brokers use that position thoughtfully and powerfully to raise the bar for collaboration.” The healthcare insurance broker market size has grown strongly in recent years. It will grow from $64.08 billion in 2025 to $70.01 billion in 2026 at a compound annual growth rate (CAGR) of 9.3%. The growth in the historic period can be attributed to increasing complexity of healthcare insurance products, growth in employersponsored health plans, rising consumer awareness of coverage options, expansion of private healthcare systems, and increased reliance on intermediary advisory services. Dani Kimlinger

Major trends in the forecast period include increasing adoption of digital broker platforms, rising demand for personalized coverage advisory, growing integration of AI-based plan comparison tools, expansion of remote and online brokerage services and enhanced focus on regulatory compliance support. HEALTH BENEFITS ADVISORS:

Health benefits advisors provide long-term, ongoing strategic partnerships and operate with a broader scope, providing consultation to employers regarding their healthcare benefits programs. Advisors often act more like an extension of the HR team with a focus on analyzing the unique needs and goals of their clients, devising comprehensive strategies to optimize healthcare benefits while controlling costs. Their primary goal is to deliver value to their clients by designing benefits programs that promote employee health and well-being while containing costs. Generally, benefits advisors often charge fees for their services, which can be structured as flat fees, hourly rates or project-based fees. This fee-based model ensures transparency and aligns the advisor’s incentives with the best interests of their clients, as they are not influenced by commissions from insurance companies. 8

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Improve Healthcare System HEALTH BENEFIT CONSULTANTS

While the terms ‘consultants’ and ‘advisors’ are often used interchangeably, there are subtle differences regarding their engagement style and focus. While advisors often focus on high-level strategy, benefits consultants tend to focus on short-term, specific projects, such as benchmarking or vendor selection. Sometimes, they emphasize technical analysis over continuous, strategic guidance. Consultants often work independently to provide analysis, while advisors act more like an extension of the HR team. Historically, consultants worked for fees and brokers/advisors for commission, but this distinction has blurred, as both often use fee-based models now. BROKERS SUPPORT ADOPTION OF OPTIMAL FUNDING MODELS

With traditional, fully insured premiums becoming unsustainable, brokers are increasingly recommending alternative funding models. They are paying close attention to rising healthcare costs as McKinsey projects employers will face a 9 to 10 percent increase through 2026 due to inflation and high-cost specialty drugs, like GLP-1s and emerging cell and gene therapies. In response, today’s astute brokers are aggressively shifting employer clients toward self-funded, level-funded and alternative risk-pooling solutions and introducing other opportunities for greater cost containment.

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Improve Healthcare System “Strong brokers know the local provider landscape, network performance data and self-funding strategies far better than most HR teams ever could, and that knowledge genuinely moves the needle on premium and claims trends,” emphasizes Howell. “That said, no broker can single-handedly solve a cost problem that’s rooted in hospital consolidation, drug pricing and chronic disease. The honest ones will tell you that. Where they earn their keep is in custom plan design, steering employees to high-value care and pressuretesting carriers – not in promising they can outrun the underlying inflation.” SELF-INSURED PLANS

Brokers are stepping in to provide strategic guidance and data analytics, treating self-funding as a critical tool for budget control rather than a niche option. McKinsey advisors anticipate that self-insured membership will grow by 1% annually through 2029 and attest that more than half of fully insured employers surveyed said it was their broker who recently advised that they transition to a self-insured model. The fast swing to self-insuring can deliver greater control, cost transparency and lower premiums, documented by a report by the Kaiser Family Foundation projecting self-insured plans will cover 75% of U.S. workers by the year 2030, with a significant uptake among large firms. Brokers are working together with Third-Party Administrators (TPAs), showing preference for TPAs that enable smooth, transparent onboarding processes that allow for immediate tracking of plan performance. Moving from transactional relationships to strategic affiliations that can integrate data systems in a shared unified data framework, these partnerships enable faster, more accurate decisions for plan sponsors. By adopting a partnership mindset and shared accountability, this level of collaboration reduces friction and leads to shared visibility into high-dollar claims with a focus on compliance with ERISA and Department of Labor audits. LEVEL-FUNDED PLANS

Brokers increasingly introduce level-funded plans as the standard for mid-sized employers, as these plans provide the predictability of fully insured models with the cost-saving potential of self-funding. They are using real-time data on claims, pharmacy spending and high-cost conditions to justify the switch and create customized, more efficient plan designs. To mitigate any concerns of financial risk, brokers are securing stop-loss insurance policies to protect employers against high-cost claims. ALTERNATIVE RISK-POOLING SOLUTIONS

As a strategic response to escalating healthcare costs, some brokers are aggressively recommending alternative risk-pooling solutions to small and midsize employers (SMBs), such as medical group captives and Individual Coverage Health Reimbursement Arrangements (ICHRAs). These solutions are designed to provide greater data transparency, cost control, and the potential to retain underwriting profit.

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Improve Healthcare System 

ICHRAs are employer-funded, tax-advantaged health benefit plans, allowing businesses of all sizes to reimburse employees for individual insurance premiums and qualified medical expenses instead of offering traditional group insurance. These plans enable personalized coverage for employees while offering employers predictable, flexible and often lower costs.



Medical group captives are a form of self-funded, member-owned insurance companies where a group of small to mid-sized employers join forces to share the risk and cost of their employee health insurance plans. Coming together, they create a captive insurance company to manage, fund and control their own medical stop-loss coverage.

Stop-Loss Carrier selection increasingly falls upon brokers who can evaluate a carrier’s reputation, financial strength and alignment with an employer’s long-term strategy. Most brokers favor carriers with a strong reputation for handling large claims, financial stability and responsiveness. Here again, such brokers collaborate with TPAs and carriers to choose the best solution, as even welldesigned stop-loss policies can fail if claims are delayed or information goes missing between parties. They bring greater understanding of how individual claims and aggregate overall plan spend align with the plan’s deductible levels, cash flow, appetite for risk and approach to lasering. NARROW AND TIERED NETWORKS

Narrow and tiered networks are not the same, though both endeavor to reduce healthcare costs by guiding patients to specific, cost-effective providers. Rising to the top of benefit broker recommendations is adoption of narrow networks as a primary strategy, utilizing more localized, high-value provider networks to achieve lower premiums and reduce out-of-pocket expenses. A study reported in Health Economics shows there’s evidence that narrow networks work. Perspectives on patient behavior and economic drivers contribute to this conclusion, as the selective nature of narrow networks allows insurers to negotiate lower prices, and the plan design steers patients to lower cost providers. Tiered networks offer a broader network, but charge different amounts based on the provider's cost, quality, efficiency or other factors. They incentivize members to seek care from preferred providers and experience higher-quality care at a lower cost, although their choice is not limited if they are willing to pay higher cost sharing. An analysis of tiered network plans in Massachusetts conducted by the Commonwealth Fund found the tiered networks were associated with a 5 percent decrease in spending — $43.36 less per member per quarter compared with per-member spending in similar plans not offering tiered networks. REFERENCE-BASED PRICING (RBP)

RBP uses an established benchmark, like Medicare, to determine what is paid for healthcare services. ELAP Services maintain that self-insured businesses can add an RBP solution to their health plan and reduce annual costs by up to 30%. RBP providers review and audit medical bills, reprice them based on Medicare or some other benchmark, like the actual cost reported by the hospital, and pay a fair markup on those charges. JULY 2026

Improve Healthcare System DATA-DRIVEN TOOLS

Sophisticated brokers are partnering with companies that offer data-driven solutions and predictive models to identify trends or tap into analytics to uncover cost-saving opportunities. This allows employers to spot high-cost trends and intervene quickly by flagging employees who might be at risk of chronic conditions or at risk for catastrophic, expensive care. DIRECT CONTRACTING

Brokers now negotiate directly with hospital systems and providers to bypass the middleman markups of traditional insurance carriers. This approach emphasizes high-value care, transparent data and improved employee access through centers of excellence, ACOs, on-site clinics and ambulatory surgery centers. The Healthcare Financial Management Association asserts that potential savings of direct contracting varies widely in type and amount between markets but ranged from 10% to 60% savings for employers. REPAIRING THE COST CRISIS

Repairing the healthcare system in the United States is a complex multifaceted issue, as Joe Dore, President, USBenefits Insurance Services, states, “In my opinion, the best place to start to address cost mitigation is with the employer, because it’s their pocketbook and they should be aware of the economics and the components that contribute to their healthcare costs.” While it’s quick and easy to point to the provider, pharmacist and network as the problem, he believes there are risk management strategies that can mitigate these costs. Some things for the employer to consider:



Take accountability for the execution of the strategic objectives and compliance with the Plan Document.



Ensure that the broker, TPA, vendors and stop-loss carrier are in alignment with the preceding bullet point to deliver the best possible outcome.



Understand how claims affect the premium, especially those exceeding the deductible.



Require that all parties aggressively and relentlessly pursue the best outcome.

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Improve Healthcare System “Often, providers hide behind network contracts, which ‘supposedly’ stipulate no audits are permitted,” continues Dore. “Furthermore, it’s common for vendor audits to pursue coding issues and duplicate charges.”

Joe Dore

He emphasizes that the healthcare industry has conditioned the payer not to cause friction, adding, “Therefore, the employer should demand deeper dives into their medical bills for erroneous charges, medically unnecessary services and matters that may be a conflict of interest among parties. I believe employers who are educated on this topic and are involved throughout the policy period will experience greater transparency and diligence from all parties for maximum performance.”

When it comes to containing costs, Kimlinger notes, “We’ve seen incredible examples of brokers leading this work. In one case, a broker convened all of a client’s service providers not to showcase products, but to deeply understand one another’s roles. Providers then were asked to map integration opportunities together, then go home and deliver a shared strategy. There was resistance from some vendors, but the message was clear: if you want to stay on this team, collaboration and integration are not optional. This can turn into real cost and care strategy.” COST CONTAINMENT VS. COST MANAGEMENT

Roffé projects that the brokers who win going forward will embrace data, own outcomes and challenge carriers and legacy models. “Brokers can support the development of integrated, value-based ecosystems, assuming a clear role as operator and problem solver for cost management – after the cost occurs, as well as advisor and strategist for cost containment before the claims occur,” says Roffé. “If costs rise again when the program stops, it was never containment.” He justifies that repricing claims isn’t enough, adding, “What brokers need to communicate is about true cost containment. Medical cost growth continues to outpace wages and inflation, putting pressure on employers, health plans, providers and members. Beneath the headline numbers are real tradeoffs— between access, outcomes and affordability—that don’t have easy answers.” Despite the arrival of new solutions, healthcare costs keep rising, leaving employers to believe that nothing is working. “Brokers are being asked harder questions,” says Roffé. “This conversation matters because medical cost containment is no longer a carrier problem or an employer problem—it’s a broker value proposition. In today’s market, brokers aren’t judged necessarily on plans—they’re judged on whether costs are under control.” Roffé perceives that employers don’t think brokers are failing — they just think the system is failing. “Today, the opportunity for brokers and solutions providers is to explain it clearly… and fix the parts that aren’t working, he notes. “The modern broker challenge is being expected to control healthcare costs in a system that resists control—while still proving measurable value every renewal. Brokers aren’t being replaced by technology or carriers—they’re being replaced by brokers who can explain, execute, and defend a cost strategy.” JULY 2026

Improve Healthcare System BROKERS OFFER INNOVATIVE, OFTEN UNCONVENTIONAL SOLUTIONS

Brokers are positioned to move the dial on helping employers enhance recruitment and retention efforts without inflating expenses. Curated, technology-enabled, and highly personalized benefits packages supported by data-driven strategies have wide appeal: McKinsey estimates that by 2030, approximately 12 million members could move to innovative products that offer 10% to 30% savings compared to traditional PPOs.

There are also some alternative programs that have high perceived value, including expanded fertility benefits, enrollment support, caregiving support platforms or niche programs that help employees stay focused and productive during demanding life transitions. Virtual-First has become a staple as telehealth or remote monitoring using a comprehensive ecosystem of digital tools and artificial intelligence (AI) extend care beyond the physical walls of a clinic or office setting. Employee engagement solution providers emphasize that a benefit is only valuable if employees understand the options and take advantage of the features. Static portals and generic plan comparisons simply fail to meet workforce expectations, and brokers gravitate toward recommending integrated and personalized solutions that reflect individual needs and preferences. The underpinning of AI-driven support is fast becoming essential, as the Annual Benefits Broker Report from Optavise estimates that 59% of brokers now use AI to improve employee decision-making and enrollment and 57% use AI to create personalized benefits education and communication. 16

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Expanded fertility benefits are in great demand as employers look for new ways to attract and retain talent as well as enhance employees’ mental health, performance and loyalty. Astute brokers are making fertility coverage an increasingly essential component of a competitive benefits package, as Maven Clinic’s 2025 State of Women’s and Family Health Benefits report shows two-thirds of employers plan to invest in family health benefits within the next three years, a 44% increase since 2024. Reshaping Wellness is also commanding attention as benefits brokers redefine this category of solutions to shift from generic, one-size-fits-all programs toward practical, integrated tools that address mental health, financial stability and physical well-being. McKinsey’s Future of Wellness research shows Generation Z and Millennials place high value on holistic well-being, flexibility, and inclusiveness, and are seeking support to manage high levels of stress, burnout, anxiety and worry. Younger workers are more willing to invest in wellness products and services -- from recovery solutions and skin and hair care to nutrition support. They expect a personalized, science-based, and holistic approach that supports recovery and long-term well-being. Employees are also prioritizing financial wellness as economic uncertainty and rising healthcare and living costs are contributing to workplace well-being. Brokers understand that their clients need expanded financial education and support through benefits that may include student loan repayment options, employee assistance programs and on-site workshops. Lifestyle Spending Accounts (LSAs) have captured the interest of benefits brokers, offering an employerfunded reimbursement benefit for lifestyle expenses. Employees submit receipts for approved purchases and are reimbursed through payroll with the appropriate tax treatment. Employers define which categories are eligible -- wellness, food, learning or connectivity -- how much funding is available, who is eligible and when and how expenses should be treated for tax and payroll purposes. Categories span: All-Inclusive LSA, Cell and Internet, Charitable Giving, Commuter Expenses, Co-working, Culture, Experiences and Entertainment, Family and Caregiving, Food, Office Equipment, Out-of-State Care, Pets and more. 18

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Improve Healthcare System

Chronic Condition Management has become an overriding concern as employers turn to their brokers for structured programs that move beyond just covering drugs to promoting comprehensive, whole-person strategies. Given the meteoric uptake of GLP1s, brokers are urging clients to integrate high-cost GLP-1 medications within broader, evidence-based programs that combine medication with lifestyle, nutritional and behavioral support to manage both cost and health outcomes. Requirements for GLP-1 Coverage for Obesity, 2025

Source: Business Group on Health There’s also emphasis on basic strategies to invest in early, evidence-based screening to identify health issues before they progress to complex diseases requiring expensive interventions and resulting in highcost claims. BROKERS FOCUS ON SMART RISK PHARMACY MANAGEMENT

As a health benefits line item, the surging financial risks of budget-shattering pharmacy costs have moved into first place, accounting for 24% to 30% of total employer healthcare costs (Insurica). As renewal season gets underway, employers call upon their brokers to recommend proactive steps that can effectively tackle these expenditures. Aligning with government reforms to Pharmacy Benefit Management, brokers are advising clients to "unbundle" their pharmacy benefits from medical carriers, allowing employers to carve-out pharmacy management to alternative or transparent PBMs as opposed to the "Big 3" legacy PBMs. Brokers are helping clients to bring their PBM contracts into compliance and provide full disclosure of compensation, rebates and fees as required by the new regulations of the Consolidated Appropriations Act of 2026 (CAA) and Department of Labor (DOL) proposed rules. They are selecting PBMs that provide 100% rebate pass-through, eliminate spread pricing and use transparent, flat-fee models rather than percentage-based fees, utilizing advanced tools to identify cost drivers, monitor compliance and support the efforts of plan sponsors to fulfill their fiduciary responsibilities. 20 THE SELF-INSURER

Improve Healthcare System

Source: Business Group on Health Given that specialty medications account for over half of total pharmacy spend and now account for an estimated 80% of new drug approvals, brokers are separating specialty drugs from the general medical plan. They are working collaboratively to create custom pharmacy management or carve-outs for highcost therapies, including GLP-1 weight management drugs, cell and gene therapies and oncology drugs. Brokers are also urging biosimilar adoption and persuading employers to implement ‘biosimilar-first’ formularies which can potentially deliver savings of 25% to 85% over expensive brand-name biologics. Brokers are also responding to the newest phenomenon – Direct-to-Consumer drug purchasing, leveraging a growing number of manufacturer online platforms that bypass traditional retail pharmacies and PBM markups for specific high-cost drugs. As trusted advisors, brokers can guide employers regarding the financial impact of these programs on their health plans. When patients spend outside their health plans, drug manufacturer rebates are not generated, which can limit financial benefits to the plan and its participants. Another concern is the proliferation of pharmacy deserts, prompting plan sponsors to turn to their brokers for suggesting alternatives like enhanced mail-order services, virtual pharmacy consultations and integrated wellness initiatives. Some brokers are taking a more progressive approach to address high specialty drug costs, along with recommendations to integrate international sourcing of medications. This option remains complex and may expose plan sponsors to legal and compliance risks if not properly designed and administered. Findings of the new Lockton 2026 National Benefits Survey, however, indicate that 46% of self-funded plan sponsors say they would consider international drug sourcing for pharmacy benefits and 7% of respondents are already using international sourcing for pharmacy benefits. TECHNOLOGY IS KEY TO DELIVERING VALUE

Benefits brokers earn the trust and respect of self-insured employers when they connect business goals with a benefits strategy. To deliver that kind of value requires a practical framework with underpinning technology that produces data-driven insights and endpoint JULY 2026

Improve Healthcare System results that successfully address the issues that matter most to employers today. In fact, as healthcare costs and plan options multiply, it is common for benefit brokers to find that what worked last year will not work going forward. In the renewal process, many brokers are leveraging AI-generated guidance to provide product suggestions based on the evolving needs of a client's workforce, rather than a broker spending hours searching and comparing. The role of the broker has become so tech-dependent that 4 in 10 employers say they would switch brokers if their current one couldn't support their technology needs. That’s the reality check from Guardian where experts maintain that benefits brokers have long been the bridge between employers and the complex world of workplace benefits, helping organizations design plans that attract talent, manage costs and stay compliant. They claim that employers now use an average of 11 different systems to manage HR data and depend upon brokers to help consolidate these into unified platforms that sync

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Improve Healthcare System enrollment, payroll and compliance reporting. Employers increasingly expect their brokers to understand how benefits fit into the technology systems that power HR and payroll, presenting opportunities to strengthen client relationships, streamline administration and compete more effectively against digital-first competitors. Benefits technology sculpts employer decisions to deliver seamless, digital-first benefits experiences that optimize resources and minimize risk. Dani Kimlinger attests that when employees don’t experience benefits as separate products, they experience them as one system when life happens. “Brokers who translate benefits across vendors, reinforce how programs connect, and set expectations for year-round coordination help employees use what employers pay for,” she comments. “That systemslevel clarity is where brokers reinforce their advisory value well beyond open enrollment. They have the authority to be system integrator.” When it comes to brokers recommending a new product or service, Optavise cites the importance of technology, citing the top three factors: 59% Ease of Integration, 54% Employee Experience and 43% Innovative Technology. Brokers prove their value by keeping pace with technology that supports data integration, enrollment systems and employee communication tools that ease benefits management. OVERCOMING CHALLENGES OF DATA INTEGRATION

Integration is a constant challenge, as Deloitte attests that the market is shifting its focus from contingent and full-time labor intelligence to “total workforce intelligence.” They cite findings from a recent study (Second Talent) showing 76% of organizations cite HR analytics as a strategic business priority—yet only 6% have reached predictive maturity. Brokers recognize that it’s no longer sufficient to just obtain external data— they take their cue from industry thought leaders who say the time has come to manage the entire data supply chain. The above-referenced study confirms that the adoption of HR analytics varies significantly across organizations, with maturity levels ranging from basic reporting to advanced predictive modeling. McKinsey affirms that organizations with mature HR analytics programs are 5x more likely to make fast, data-driven decisions and 3.2x more likely to outperform competitors. Source: McKinsey People Analytics Research 24

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Improve Healthcare System Second Talent cites key adoption drivers: •

87% of organizations cite “better decision-making” as primary driver

•

79% want to improve employee retention and engagement

•

73% seek to optimize recruitment and hiring processes

•

68% aim to demonstrate HR’s business value

•

62% focus on cost reduction and efficiency gains

•

75% want to enhance workforce planning capabilities

•

54% need to support compliance and risk management

•

49% seek competitive advantage through people insights

Brokers demonstrate value by expressing their willingness to discuss issues related to data exchange, automation and decision-support tools. Tech-savvy brokers use these communications to validate their understanding of business beyond benefits alone, providing data-driven insights and translating complex benefits issues into clear, actionable strategies. BENEFIT BROKER SOLUTIONS TACKLE PERSISTENT EMPLOYER CHALLENGES

“Advocacy is the area with the widest gap between what brokers promise and what they actually deliver,” maintains Barbora Howell. “Many sell ‘concierge’ services that turn into a voicemail when an employee is fighting a denied claim or a surprise bill. The brokers who do this well either staff dedicated patientadvocacy teams or partner with specialized advocacy firms who can navigate appeals, billing errors and prior-auth disputes on the member’s behalf.” Howell advises plan sponsors: “The right question isn’t whether your broker offers advocacy…it’s what happens when an employee actually picks up the phone and whether anyone is measuring outcomes on those cases.” Laura Carabello holds a degree in Journalism from the Newhouse School of Communications at Syracuse University, is a recognized expert in medical travel and is a widely published writer on healthcare issues. She is a Principal at CPR Strategic Marketing Communications. www.cpronline.com

JULY 2026

F E AT U R E

Rethinking

Stop Loss

From leveraging adaptive captive to weekly aggregate accommodations, self-insured health plans are trying novel approaches to ease the sting of a hardened market

Written By Bruce Shutan

n response to a hardened stop-loss insurance market, pressure is mounting on self-insured employers to employ novel strategies that generate more meaningful results. One such approach involves building hyper-targeted financial solutions that shield employers from financial uncertainty. The idea is to leverage adaptive capital to eliminate an employer’s stop-loss reimbursement lag and improve their cash position, according to Gerardo Zampaglione, Founder of Aegle Capital and a member of SIIA’s 2026 Cell and Gene Task Force. He points to numerous gaps in the administration of self-funded health plans that dedicated financial products can actually solve. But capital must be adapted to specific use cases within the self-funded space with a set of accompanying technology tools that exists in workflows in order to actually make it useful, Zampaglione explains. As more smaller employers self-fund their group health benefits, some stop-loss carriers in cooperation with their client’s third-party administrator are offering weekly vs. typically monthly aggregate accommodations for level-funded products to speed up cash flow and limit surprise funding needs, notes Wendy Dine, Director of Strategic Risk Solutions, Inc. “It further protects the level-funded employer from any cash-flow volatility within their self-insured retention,” she explains. Separately, there are contract protections for their specific stop-loss claims.”

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Rethinking Stop Loss Sagen sees the bill-review segment moving fast as more self-insured health plans explore payment-integrity solutions, usually on a postpayment basis. “There’s something to be said for engaging early in the bill-gathering bundled-payment process that the TPAs are actually working through,” he says, noting how such efforts help with both stop-loss and captives.

Gerardo Zampaglione When aggregate performance is tracked weekly instead of monthly or annually, reimbursements that start much sooner if claims exceed the prorated threshold will have a positive impact in a number of ways. They include reducing the need to prefund excess claims, preventing cash strain on the carrier or fronting arrangement and keeping the program operating closer to the expected level-funded cash flow. Similar strategies to reduce lag times also benefit larger employers (more on that later). More advisers, third-party administrators and captives are looking for risk-management tools that can reduce, transfer and possibly eliminate risk in the medical stop-loss environment, observes Dale Sagen, VP and Business Development Leader for QBE North America. He says many of them are targeting mounting catastrophic claims from specialty drug programs, as well as condition-specific items on hospital invoices involving dialysis, end-stage renal disease, cancer, musculoskeletal and prenatal care.

Expertise plays a big role in efforts to ease the sting of stop-loss. For example, benefit advisers, health plans and captives increasingly are considering contracting with outpatient surgical centers of excellence, Sagen says. They’re also taking this approach by delivering oncology infusion alternatively rather than in a hospital setting, as well as primary care inside the direct primary care model to offer greater value. Tommy Maher, SVP for RMTS LLC, cautions that while centers of excellence targeting specific Dale Sagen disease states such as cancer or musculoskeletal conditions are certainly valuable, these best-in-class treatments won’t necessarily help reduce costs. The ultimate aim, of course, is to steer covered lives to low-cost providers that offer the highest quality of care, but the challenge is verifying and quantifying their clinical outcomes. The problem is that many newer programs lack the necessary data to justify their use in the eyes of actuaries and underwriters, he says. Cell and gene therapies are full of enormous potential from a clinical standpoint, but also significant risks. Sagen says single-parent captive owners looking to reduce or remove that volatility from their self-funded retention health plan can add capacity to those risks to handle multimillion-dollar exposures. “Many are trying to put a limit on their risk,” he says, “and that’s inclusive of the cell and gene therapy. That’s where we Tommy Maher see a lot of single parent-captive owners start to gravitate back toward stop-loss as a solution that includes the cell and gene therapy risk that they are now seeing as a concern in their health plan.” JULY 2026

Rethinking Stop Loss MANAGING LARGE CLAIMS

Heading off high stop-loss renewals by actively managing large claims as they arise in real time is the key to success, Maher says, noting that there are a variety of ways to do that. “It’s identifying specialists in a specific area and leveraging their expertise to manage claims,” he suggests. Those efforts to cover treatments within a stop-loss policy at a reduced price rather than carve them out may include contracting with, say, a dialysis service to lower a self-insured group health plan’s overall exposure to costs associated with treating kidney disease. The same could be said about hiring a specialty Rx vendor to supply a $100,000 per month maintenance drug at half the cost with little to no interruption to the claimant. Some health plans, however, don’t cover cell and gene therapy risk or pharmacy costs that exceed $1,000. “At that point, you have to work with a solution that’s going to potentially source that for much less cost,” he explains. What the captive space does is allow self-funded employers to create policies and coverages that are creatively customized to meet their own needs, he adds. Some captives are asking for medical stop-loss with a fronting carrier or assuming the risk within their captive with a reinsurance partner at a higher limit than they would typically be able to procure in the stoploss market.

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Rethinking Stop Loss “The fronting arrangement is one of a couple of ways that you can transfer risk into your captive,” Sagen explains. “It adds value because you have a rated policy from an admitted insurer in your state. You have the underwriter, claims, policy issuance, actuarial – everything that insurers bring to the table, you are effectively bringing that into your captive.”

stop-loss, providing “the best of both worlds.” In essence, they’re able to leverage the advantage of self-funding alongside financial protections and dividends from the captive in a good claims year.

Since most captive owners, especially in today’s market, are uncomfortable with taking unlimited risk, he says they effectively look toward the reinsurance market to limit their exposure. “You can create a limit that makes you a little bit more comfortable based on the capital that you’ve exposed in your captive,” he says.

In addition, stop-loss carriers and captive program managers are seeing an influx of self-insured, midsize employers pooling their risk to tap into more resources, better understand their claim activity and reduce some of that volatility, according to Dine.

What group captive participants have essentially signaled to their underwriter is that putting up collateral to join forces with like-minded employers shows a willingness to take on a bit more risk for the ability to self-fund, Sagen observes. This, in turn, allows the underwriter to feel more comfortable with small and midmarket employers that are seeing some extreme volatility in the market. Strength in numbers cannot be underestimated when it comes to easing the sting of high stop-loss rates. Dine says some group medical stop-loss captive programs are being developed that allow employers that are level-funded on the front end to share in a portion of the

“If they were self-funded on their own and procuring stoploss, a carrier may look at them and say, ‘we don’t want to quote this,’ but if they’re with a larger pool, then there’s the ability to say, ‘well, we’ll write this case and won’t place all these lasers, and we want them to utilize some of those cost-management resources,’” she explains. SWEETENING BITTER PILLS

Likening managing catastrophic healthcare claims to swallowing a bitter pill, Zampaglione says one approach involves excluding various categories such as cell and gene therapies, which amounts to avoiding the pill altogether. A second method involves paying another party to swallow the pill, which he describes as a very expensive proposition.

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Rethinking Stop Loss A third approach that his firm has developed essentially employs using a reliable knife to cut up the pill so that it’s much easier to swallow. For example, that could involve switching from a Big Three pharmacy benefit manager to a transparent or fiduciary PBM. But there’s also a fourth angle, which he says amounts to actually shrinking a large bitter pill. That effort may involve leveraging referencebased pricing, the 340B federal drug pricing program and the No Surprises Act. Noting a universal reluctance among HR departments to exceed their budgets, his company developed a more sophisticated version of pill cutting. That levelfunded model allows employers to move a budget overage into the following year or next several years, guaranteeing they will not go over budget in a given year. “Everyone in the business knows that over a five-year timeframe, it’s really hard to come in that much over year to year to year,” he says.

THE WAITING GAME

Although the $40 billion stop-loss market has grown four times since 2013, Zampaglione says the 60% BUCA-owned solutions relative to 40% independent players have remained unchanged. Moreover, the number of self-insured employers encountering three claims of more than $1 million in a given year is up an astonishing 400% on average since 2013, he adds. It’s understandable that a private-equity-backed $7 million EBITDA business that has to wait 180 days for a $3 million claim to be reimbursed is going to be rather eager to get its hands on those funds, Zampaglione notes. The first part of that lag, anywhere from 30 to 40 days, typically involves a TPA gathering eligibility forms and other data. Then the stop-loss carrier will want to review all the charges, which consumes additional time. But self-insured employers no longer need to wait around for long periods when innovative approaches are within reach. “Where we accelerate that reimbursement is by essentially allowing the distribution partner to trigger it within 24 hours, and then we get repaid by the reinsurer directly,” he explains, citing it as an example of using institutional capital to fill gaps in the self-funded arena.

Thinking beyond standard calendar or fiscal-year objectives with regard to healthcare budgets holds great promise in the current climate, Zampaglione suggests. “If you had ways where you can start to chop up this exposure and think about it over time that help with budgeting, imagine you do an intervention where you see benefits three years from now,” he poses.

JULY 2026

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Rethinking Stop Loss The program he built has handled over $80 million of claims to more than 40 clients with anywhere from 20 to more than 30,000 lives since its inception. His goal is to push funding upstream as much as possible to insulate employers from that variability. “It’s one thing to know that you have insurance and that you will eventually be covered. It’s another one to actually have money in the bank,” he says. “You cannot make payroll if you do not physically have the money, and so we want to narrow the gap between bundled and independent stop-loss.” FOCUSING ON QUALITY CARE

Doubtful that stop-loss rates will soften anytime soon, Maher believes the market in general needs to understand the severity of some newer treatments such as cell and gene therapy opportunities that are increasing in number by the day. He says this category has grown from barely two handfuls – numbers that are expected to significantly multiply in the coming years. “Until the market can understand the gravity of that situation and prevalence of these very high-cost solutions, I think it’s going to be a hardened market for the foreseeable future,” he observes. Offering no new lasers on renewal or rate-cap programs is a frightening proposition in the face of multimillion-dollar cell and gene therapy solutions, not to mention the rate at which even medical expenses have risen, he adds. Dine recalls how someone actually referred to the existence of a tightening rather than hardened stop-loss insurance market. Her sense is that employers are being smarter with their underwriting and in assessing their risk appetite.

JULY 2026

Rethinking Stop Loss She believes some managing general underwriters – particularly those that have been less disciplined in recent years – will face ongoing pressure due to the excess reinsurance market increasing rates and tightening underwriting guidelines that may have been overlooked. Direct writers, who she says for the most part have been more disciplined and not as dependent on the excess reinsurance market, are likely to navigate this firming market. “We’re seeing a correction, not necessarily major increases that are unwarranted,” she says. “Captives certainly can benefit from that because most of these carriers, if they analyze their traditional stop-loss vs. their captive stop-loss book, will find their captives are performing better than their traditional stoploss.”

Bruce Shutan is a Portland, Oregon-based freelance writer who has closely covered the employee benefits industry for nearly 40 years.

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We study risk, research it, speak on it, share insights on it and pioneer new ways to manage it. With underwriters who have many years of experience as well as deep specialty and technical expertise, we’re proud to be known as experts in understanding risk. We continually search for fresh approaches, respond proactively to market changes, and bring new flexibility to our products. Our clients have been benefiting from our expertise for over 50 years. To be prepared for what tomorrow brings, contact us for all your medical stop loss and organ transplant insurance needs.

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INNOVATIVE MENTAL HEALTH SOLUTIONS EASE PRESSURES ON ACCESS TO CARE

Written By Laura Carabello

ust a year ago on July 4, 2025, media reports of the catastrophic Texas Hill Country floods shared alarming statistics: 135 lives lost, including 37 children, as intense, slow-moving thunderstorms delivered up to 12 inches of rain, causing the Guadalupe River to surge nearly 20 feet in 15 minutes, surpassing 1987 records and devastating areas like Camp Mystic. But it wasn’t until early 2026 that mental health assessments indicated that the July 4th floods caused widespread trauma, predicting over 6,000 new post-traumatic stress disorder PTSD cases in adults and 2,000 cases of serious emotional disturbance in children. Professionals point to symptoms, including anxiety and grief, which are expected to intensify and last for years without intervention. Experts warn that trauma-related symptoms often worsen months after the initial disaster and can last for years as they are linked to the destruction of homes and loss of life in the region. This is a high-profile event that resulted in PTSD, one of the most challenging mental health conditions to diagnose. Think of all the tragic shootings, disastrous weather events and violence that result in PTSD and a panoply of behavioral health-related disorders that involve significant, diagnosable disturbances in thinking, emotional regulation or behavior that impair daily functioning. It’s no surprise that anxiety, depression, and co-occurring substance use disorders (SUDs) top the list of mental illnesses prevalent in US adults, according to the American Psychological Association (APA). 36

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APA data also indicate that although the Veterans’ Association is expanding community care, workforce shortages and administrative bottlenecks continue to delay care for veterans, with some studies indicating that 11-20% of Iraq/Afghanistan veterans suffer from PTSD. Even young children playing football are at risk for anxiety and depression. Children’s mental health is an increasing source of stress for parents, the survey by The Kids Mental Health Foundation found. Two of the top sources of stress are children’s behavioral issues or children’s emotional and mental health. At the start of 2026, more than one in three Americans (38%) say they plan to make a mental health-related New Year’s resolution, according to new findings from the American Psychiatric Association’s Healthy Minds Poll. Anxiety remains commonplace among Americans, as the American Psychiatric Association reports that in 2026, people express that they are feeling anxious about personal finances (59%), uncertainty about the next year (53%), and current events (49%), with concerns about physical and mental health close behind. Health data analytics and market research firm Trilliant Health further confirms that anxiety disorders accounted for the highest visit volume and experienced the fastest growth, up 89% from 2018 to 2024. Anxiety disorders in women aged 18-44 were also the highest utilization category. The increased scope and sheer volume of traumatic events in every community nationwide have boosted the need for therapy across the country. In response to record-level demand, the way people seek care is changing faster than ever. The Substance Abuse and Mental Health Services Administration (SAMHSA) documents more than 1 in 5 U.S. adults experience mental illness each year. Yet, access to mental healthcare remains a significant, systemic problem in the U.S., driven by clinician shortages, high costs and insurance limitations. While public awareness and telehealth/virtual options have expanded, over 122 million Americans live in underserved areas or marginalized communities, and nearly 3 in 10 adults with serious mental illness face disproportionate hurdles to finding consistent care. What’s more, young people are experiencing higher rates of depression and anxiety.

JULY 2026

STRATEGIES TO ADDRESS MENTAL HEALTH, 2026

Source: Business Group on Health This is alarming for both employers and employees, since the persistence of barriers to mental health services also translates into profound physical and financial consequences on other areas: the risk of cardiovascular disease are twice as high in people with mental illness compared to those without, exposing plans to expensive treatment costs. Having a mental illness also increases the risk of other conditions, such as obesity, strained relationships and job loss. Regrettably, it often results in severe social issues and high rates of suicide or premature death. Employers are being put on notice regarding access to care. A benefits compliance attorney at the NonFarm Payrolls (NFP), which issues a monthly US employment report from the Bureau of Labor Statistics, warns employers to listen carefully to employees' complaints about access to mental healthcare. A statement from the U.S. Department of Labor's Employee Benefits Security Administration says it is prioritizing removing barriers to accessing mental health and substance use disorder benefits. Thankfully, emerging and innovative solutions are easing access to affordable, accurate diagnosis and effective care that relieves the pressure on traditional care systems and addresses dissipating clinician bandwidth – a positive development for the self-insured community.

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82% see a change in treatment plan

Source: Lyra Health CONNECTING MEMBERS TO CLINICIANS

A key barrier to accessing mental healthcare is that 80% of directories are inaccurate, and "in-network" providers are often not actually available. Members are experiencing high levels of frustration when seeking mental health providers due to a combination of severe provider shortages, insurance-related obstacles and the "ghost network" phenomenon, where directories list providers who are unavailable or out-of-network. More than 122 million Americans live in Mental Health Professional Shortage Areas, making access to timely, in-network care difficult. Trevor Colhoun, CEO, TPN.Health, a national behavioral health platform, explains the value of an approach that pairs clinician engagement with care navigation to improve access to care. “With more than 120,000 behavioral health providers using TPN.health regularly for free continuing education, license tracking, peer connection and now referrals, we have real-time visibility into who is active, what they treat, where they work, which states they are licensed in and whether they are accepting new patients,” he states. “Providers log in an average of over 7 times per month, giving us an accurate picture of which clinicians are available.” He says TPN.match pairs that live clinician data with a Care Navigator who works directly with the member. “When the member recognizes they need help, instead of starting a directory search they text a number to get connected to a licensed Care Navigator,” he continues. “The member does not need to self-diagnose, decode a network, or call multiple offices to try to make an appointment with a provider who might not be a fit for them. Their dedicated Care Navigator gathers clinical and personal context, then routes them to the right care based on their needs and preferences, whether that is outpatient therapy or a specialty program.” This dual capability is particularly important in rural and underserved areas, where traditional networks are thinnest. “Care Navigators support members in accessing in-person or virtual care and can draw on our extensive network of providers that span the full continuum of care, to find the right provider, not just a provider,” says Colhoun. “What separates TPN.health from other behavioral health access solutions is a national, engaged provider base, up-to-date availability and provider specialty data and human-led Care Navigation to meet the member in the moment and guide them through the process of finding the right care.” On average, members receive a response to their text within 10 minutes, are placed within 1 business day and their first visit takes place within 7 days. The time to first appointment improves 92%, patient-provider match accuracy reaches 95.2%, and treatment dropout falls by 65%. 40

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“Additionally, we provide comprehensive credentialing and claims processing, further streamlining all procedures associated with provider flow to seamlessly deliver accurate qualifications and clean claims,” he states. “This results in lower costs to the employer – a significant benefit that helps them to lower the total cost of care.” By utilizing the front-end care navigator as a starting point, Colhoun says employers realize 15% savings on claims that result from elimination of unnecessary, historically billed claims visits. “This approach reduces both administrative and medical costs by purging bad claims data, improving credentialing and network management and significantly enhancing member satisfaction,” concludes. Access to Care Ranking

Source: U.S. Census Bureau 2021 boundaries , summitpost.org The approaches most clearly easing access pressures today are not defined by a single technology, but by how systems redesign the pathway into care. Dani Kimlinger, PhD, MHA, SPHR, SHRM-SCP, CEO, Mines and Associates, says, “Across employer-sponsored and self-insured environments, progress is coming from models that reduce friction at first contact, identify urgency and complexity early, and route individuals to the appropriate level of support without delay. These models often combine digital entry points with live, clinically governed triage and continuous availability, including clear escalation protocols.” She explains that a defining feature of these approaches is flexibility rather than limitation, adding, “Individuals are offered multiple pathways into support and the ability to choose how they engage based on preference, comfort, and need. Therapy remains readily available, while other modalities such as coaching, skillsbased tools, or immersive and virtual supports can be used alongside therapy or instead of.” 42

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Kimlinger advises that increasingly, care models are also paying closer attention to fit: matching people not only by clinical need, but by modality preference, areas of provider expertise, cultural competence, and in some cases, shared lived experience: “This combination of choice, personalization, and coordination helps expand capacity while preserving meaningful human connection and timely access, particularly for individuals with higherrisk or more complex concerns that carry significant clinical and organizational impact for selfinsured plans.” EYES ARE THE WINDOW TO THE BRAIN

Until now, diagnosing mental health disorders has remained a major challenge due to reliance upon subjective, self-reported symptoms, high symptom overlap between conditions and a lack of objective biological tests. That’s why one of the most extraordinary mental health diagnostic and treatment monitoring solutions is a first-of-its-kind AI-powered platform from Senseye that uses a smartphone to accurately measure mental health conditions and track their severity at scale. This platform that gives clinicians a tool that turns the mind into something measurable also enables continuous monitoring over time to track severity and treatment response. For self-insured employers, this translates into lower overall healthcare expenditures since members use their own smartphones, eliminating hardware costs and clinic visits. Scalable across care settings, the solution can be deployed at on-site clinics or via telehealth, primary care, hospital and health systems, payviders, pharmaceutical clinical trials, the Veteran Administration and beyond. “Senseye has built the first ever mental health diagnostic that transitions the behavioral health diagnosis from subjective self-reporting to objective measurement,” says David Zakariaie, founder and CEO of Senseye. “Senseye is engaging with the FDA in a Phase 3 clinical study to bring a diagnostic test for PTSD to market, with near-future plans to expand into anxiety, depression, neuro-monitoring and human performance. We started with PTSD, targeting FDA De Novo submission in late 2026, since it is widely considered one of the most challenging mental health conditions to diagnose due to its complex symptoms and high comorbidity with other disorders.” David Zakariaie

Historically, PTSD has lacked a single, objective diagnostic test. But the correct PTSD diagnosis unmasks other conditions that were being missed or miscoded.

“PTSD shares symptoms with depression, anxiety, and substance use disorders,” he explains. “Patients cycling through the system with undiagnosed PTSD tend to carry unrecognized comorbidities — severe depression that was logged as mild, substance use that went unaddressed and medical conditions that were never connected to the psychiatric picture. Once the correct primary diagnosis comes into focus, the rest of the clinical picture follows.” One of the key value points of Senseye is that the same ocular engine for diagnosing PTSD also supports depression, Traumatic Brain Injury, Alzheimer's and beyond. “Each new condition is additive, not a rebuild,” says Zakariaie.

JULY 2026

Objective, clinical-grade measurement in an accessible platform aims to reduce the barriers and ambiguity for each diagnosis, helping to support timely intervention and monitoring over time to track treatment response longitudinally. Patients simply reach in their pockets and use the front-facing camera on a smartphone to access Senseye’s patented measurement interface. “It is now possible to use this readily available, no-cost device to capture an objective, non-invasive measurement of brain function within minutes — anytime and anywhere a patient meets a smartphone screen,” he states. “This breakthrough solution eliminates resource-intensive procedures, lab tests and inperson clinic visits. Access to care is getting the significant boost it desperately needs.” PSYCHEDELICS

A recently issued new executive order (EO) to speed up reviews of certain psychedelic drugs could provide new tools as a possible solution to the mental health access crisis. Zakariaie lauds the EO, adding, “While psychedelics offer great promise, they continually suffer from the lack of objective data to validate safety and efficacy,” he observes. “The Senseye platform answers these unmet market needs and we join the growing number of advocates and developers of psychedelic therapies that remain hopeful that new government approaches to the drugs will accelerate their use.” The sweeping EO directs federal agencies to fast-track research into psychedelic drugs, after a direct text message exchange with podcast host Joe Rogan marked a rapid policy shift inside the White House. The directive aims to accelerate federal review of substances, such as ibogaine and LSD which remain classified as Schedule I drugs under federal law. The order also directs the Food and Drug Administration (FDA) to expedite breakthrough therapy designations, encourages interagency data sharing and opens the door to rapid scheduling if safety and efficacy are demonstrated. This would be particularly helpful for veterans who have used psychedelics to overcome hard-to-treat conditions, from depression to PTSD and substance abuse. While the order does not actually reschedule any drugs or change legislation, many advocates and researchers welcomed the move, saying it signals high-level interest in advancing psychedelics as treatments and could help ease bottlenecks in expanding access. Expediting some psychedelics as breakthrough drugs, including ibogaine compounds, as well as allowing them to be used through right-to-try legislation, will also allow patients who have been diagnosed with life-threatening conditions to try experimental drugs outside of usual regulatory pathways. The order also calls on federal agencies to rethink enforcement of federal laws for such drugs that are proving promising in clinical research. 44

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Interestingly, the State of Texas recently enacted a law committing public funds to research ibogaine, which is made from the root of an African shrub and shows promise in treating opioid use disorder, among other conditions. MEDICAL CANNABIS

Broadly defined, medical marijuana or medical cannabis, refers to the use of the Cannabis sativa plant and its cannabinoids: tetrahydrocannabinol (THC), which causes psychoactive effects, and cannabidiol (CBD), which does not. It is used to treat specific symptoms and conditions under the recommendation of a healthcare professional and according to state regulations. The breaking news reported in Axios is that acting Attorney General Todd Blanche ordered the immediate reclassification of FDA-approved and state-licensed marijuana as a less dangerous drug, shifting it from a Schedule I drug -- currently grouped with heroin and LSD -- to a category alongside substances like ketamine and steroids. Look for the results of a hearing scheduled for late June which is expected to provide a "pathway to evaluate broader changes" to the drug's status under federal law. Karen O’Keefe, state policy director at the Marijuana Policy Project (MPP), states, “Federal law is on the brink of finally acknowledging cannabis has accepted medical use and that it is less risky than opioids.” What is even more encouraging is that there is now clinically guided cannabis therapy for self-funded employers. This may be a novel employer benefit today, but the evidence suggests it will be a standard feature of every forward-thinking health plan in the years ahead. For self-funded employers already bearing the full cost of claims, the case is increasingly hard to ignore. Emily Fisher, CEO and Founder of Leafwell, a leading direct-to-patient medical cannabis telehealth platform in the United States, says, "The federal rescheduling of medical cannabis to Schedule III this week is a landmark moment and long overdue recognition that cannabis is a medicine. For Leafwell, it validates what we have built over six years: a physicianled clinical platform designed to bring medical cannabis into the mainstream of healthcare. For self-funded employers, it removes one more layer of hesitation. The science was always there. Now federal policy is catching up." Leafwell currently serves more than 700,000 patients with physician-led care for hard-to-treat chronic conditions such as chronic pain, anxiety, mental health conditions, sleep disorders, and the side effects of cancer treatment. These are the conditions driving the majority of employer claims spend. Today, Leafwell connects individuals with licensed physicians via HIPAA-compliant telehealth consultations, delivers personalized care plans, and supports ongoing therapeutic outcomes through a national dispensary network. “Leafwell was built on a simple conviction: medical cannabis is a medicine, and patients deserve access to it through a rigorous clinical framework, not a fragmented, unmanaged marketplace,” continues Fisher, a two-time breast cancer survivor. “The clinical outcomes are compelling: Leafwell's own peer-reviewed research, published in Pharmacy (2025) using causal inference methodology, found that medically certified cannabis patients experienced a 35% reduction in emergency department visits. A separate published study in Applied Health Economics and Health Policy estimates that employer adoption of medical cannabis programs could save US employers $22.9 billion annually.” Critically, Leafwell's care plans are designed around therapeutic, non-impairing doses — providing employees with meaningful symptom relief so they feel better, stay present, and perform. They are compliance-safe, HIPAA-compliant with zero ERISA complexity. “Productivity and workforce health are every employer's primary objective,” says Fisher. “We are building the claimsbased analysis infrastructure to measure exactly that.”

JULY 2026

According to the National Conference of State Legislatures, 40 states, 3 territories and the District of Columbia allow the medical use of cannabis products as of June 26, 2025.

Source: National Conference of State Legislatures 46

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Further sending a strong market signal on the use of medical cannabis, two companion bills, New Jersey S3984 and New Jersey A1023, were recently introduced, which would require workers’ comp, PIP and health insurance coverage for the medical use of cannabis under certain circumstances. While the bills do not specifically call out what constitutes the medical use of cannabis, they do note that scientific data indicates that cannabis has significant medical value when used in the treatment of certain injuries and diseases, including pain relief, control of nausea and vomiting, appetite stimulation, and relieving some of the symptoms of HIV/AIDS, cancer, glaucoma, and multiple sclerosis. TELEHEALTH AND VIRTUAL CARE

Most clinicians agree that both in-person and virtual therapy are clinically equivalent for the vast majority of mental health conditions — including anxiety, depression, PTSD, eating disorders, and physiotherapy. A landmark 2024 study analyzing 27,500+ patients published in Nature Mental Health found online therapy equally effective as in-person care while being more cost-efficient and faster to access. Moreover, a 2025 EBRI survey shows 73% of U.S. employers now offer virtual mental health benefits as part of core wellness programs. Clinicians at Grow Therapy attest that despite technological expansion, over 122 million Americans still live in areas underserved by mental health providers, with rural communities and people with language barriers particularly affected. Virtual care is reshaping who can finally receive treatment: older adults, multilingual families, and people with disabilities — groups historically left out of the mental health system — are using telehealth to overcome geographic constraints, mobility challenges, and cultural mismatches. Virtual access isn’t just replacing in-person therapy -- it’s opening the door for people who previously had no realistic path to care. Telehealth mental health services—whether valuebased integrated care, telepsychiatry, or employer benefits—depend upon two things: reliable outcome measurement and lowfriction monitoring between visits. 48

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“Objective, software-based tools running on mobile phones can deliver both by turning remote behavioral health into genuine measurement-based care rather than sporadic check-ins,” points out Senseye’s David Zakariaie. “Evidence across depression and anxiety care shows that when clinicians systematically track validated symptom trajectories and use them to adjust treatment, response and remission rates improve substantially compared with usual care, without overburdening patients.” He explains that these same tools align closely with long-term federal digital health priorities, which emphasize datadriven care, interoperability and equity rather than any one specific program or rule. National health IT strategies consistently call for secure, standardized exchange of health information, better integration of behavioral health, and expanded use of digital technologies that let patients generate and share their own data. “A single Software as a Medical Devicebased (SaMD) mental health measure that tracks severity over time and connects to clinical systems supports this direction: it creates sharable, comparable outcome data that can power quality improvement, valuebased contracts, and research across settings, including telehealth,” he continues. Furthermore, rural health and Medicare valuebased care efforts also point toward scalable telebehavioral solutions that address both access and measurable outcomes, without relying on a particular year’s policy details. Across administrations, federal rural strategies repeatedly highlight telehealth, workforce extension, and remote monitoring as key ways to overcome distance, clinician shortages, and stigma in behavioral health. “A phonebased tool that objectively measures depression, anxiety, or PTSD between sessions allows rural telepsychiatry teams and primarycarebased programs to monitor larger panels, escalate care early, and document outcomes in a standardized way that can be used for payment, quality, and populationhealth purposes,” says Zakariaie. In employer-sponsored mental health benefits, the same SaMD tool links individual care to organizational value. Remote, app-based symptom tracking supports personalized teletherapy or telepsychiatry while generating anonymized, aggregate metrics on improvement, risk levels, and engagement that can be tied to absenteeism, presenteeism, and productivity. “This gives plan sponsors and benefits leaders hard data to justify investment in higherquality telehealth programs and aligns with broader value-based trends in commercial insurance and public programs: paying for better outcomes, not just more visits,” he concludes. “Across all these domains, a single, objective, mobile-delivered behavioral health measure provides a durable infrastructure that fits long-running policy priorities—digital enablement, equity, interoperability, and value—without depending on the specifics of any one regulation or pilot.” According to the Los Angeles Times, virtual therapy has graduated from being a "convenient alternative" to being a primary delivery model for mental healthcare in the USA. More Californians now receive therapy via video or phone than exclusively in person. HYBRID CARE

When it comes to inperson vs. virtual care, the strategic answer for most workforces is rarely “either/or.” Kimlinger emphasizes that each model has clear strengths and limitations, “And one of the most common missteps organizations make is assuming that a single modality, whether virtual or inperson, will work uniformly across an entire population, culture, or organization. In reality, access, engagement, and JULY 2026

outcomes are deeply influenced by social determinants of health and contextual factors that shape how care can realistically be used.” She points out that inperson care remains essential for certain acuity levels, complex comorbidity, safety concerns, and situations where face-to-face assessment is clinically preferable. It is also critical for individuals whose home environments make virtual care less viable—whether due to privacy constraints, crowded housing, unreliable internet access, caregiving responsibilities, or work schedules that limit flexibility. For some communities and roles, the physical act of going to a clinic also carries meaning related to trust, legitimacy, and relational connection that cannot be replicated digitally. “Virtual care, however, offers unmatched advantages in speed of access, geographic reach, and continuity… particularly for followups, brief interventions, and populations facing transportation barriers, long travel times, or provider shortages,” says Kimlinger. “It can also reduce stigma for individuals who prefer to seek care discreetly. The limitations emerge when risk is high and escalation pathways are weak, or when virtual options are positioned as the default rather than as one option within a broader, responsive system. In those cases, engagement can suffer, and care may feel transactional or disconnected.” A well-designed hybrid approach can meet employee demand for convenience while also supporting riskbased prioritization when it functions as a coordinated pathway rather than a menu of disconnected choices. Effective models allow individuals to enter care through the modality that fits their circumstances while ensuring that care teams can collaborate and shift modalities as needs change. This includes integrating virtual and inperson therapy, EAP resources, specialty behavioral health, primary care, and health plan or network support so that the burden of navigation does not fall on the individual. “Hybrid models are most effective when they are flexible by design: responsive to lived realities, respectful of preference and culture, and supported by clinically governed triage, warm handoffs, and ongoing followup,” she explains. “When virtual access, inperson care, and coordinated escalation are intentionally woven together, organizations can preserve clinician capacity, reduce dropoff, and support continuity and outcomes for both everyday needs and higherimpact cases without forcing a onesizefitsall solution onto a diverse workforce.” TEXT-BASED MENTAL HEALTH SUPPORT

Growing in popularity, this accessible form of therapy or crisis intervention is conducted entirely through written messages, such as SMS, chat apps, or platform messaging. It includes both professional, asynchronous therapy for ongoing care and 24/7, immediate crisis support for immediate de-escalation. Key aspects of text-based care include: •

Asynchronous therapy that allows you to message a licensed therapist anytime, with responses typically provided daily, offering flexibility for busy schedules.

•

Live chat therapy that schedules real-time texting sessions with a therapist, often as effective as video for anxiety and depression.

•

Crisis text lines offering immediate, 24/7 support for mental health crises or intense distress, connecting users to trained volunteers.

The effectiveness of this approach is documented in studies showing it can be as effective as in-person, traditional or video-based therapy for conditions like depression and PTSD. It is often preferred by those in rural areas, individuals with busy schedules, or those who find face-to-face, or even video, communication 50

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daunting. While helpful for support, it is not ideal for severe, acute, or emergency situations that require immediate, high-level, in-person care. Johnny Crowder, CRPS-Y|A, founder & CEO Cope Notes, an infinitely scalable, text-based mental health support service built to reduce pressure on traditional care systems, says, ”The messages are written by real people (not AI), providing evidence-based interventions without relying on clinician bandwidth. Because it's mobile and asynchronous, it bypasses geographic barriers and fits easily into employees’ daily routines.”

Johnny Crowder

By delivering daily, bite-sized health education and peer support, he maintains that this support consistently drives higher engagement than traditional EAPs. The program extends support between appointments and reaches employees who might not otherwise seek care, helping improve outcomes while managing costs.

DIGITAL TOOLS AND VIRTUAL REALITY (VR) ADDRESS MENTAL HEALTH BENEFIT CHALLENGES

Digital tools are emerging as essential components for addressing mental health benefit challenges by enhancing access, managing costs and enabling continuous care – making it easier to monitor and improve mental well-being. People can use apps and wearable technology to track sleep, nutrition, mindfulness and other aspects of their lives, providing supplemental data that therapists can use to assess care needs. Telehealth makes this coordination seamless, enabling providers to discuss progress or setbacks in real time. Virtual Reality (VR) emerges as an innovative approach. Nature Medicine defines VR as a “computergenerated three-dimensional (3D) simulation, such as a set of images and sounds of real-life situations, with which one can interact in a seemingly realistic way by using special electronic equipment.” A simple off-the-shelf VR headset, developed for use in video games and software that creates a virtual environment enables psychologists to use VR to assess or treat patients. Research indicates that VR therapy is effective, with success rates of 66–90% in treating PTSD and is increasingly utilized in clinical settings. Researchers advise that it is particularly effective for exposure therapy, anxiety management and PTSD, allowing patients to confront fears or practice coping mechanisms in safe scenarios, such as phobia treatment, social anxiety and mindfulness exercises. VR has also expanded to other mental health disorders such as PTSD, SUDs, eating disorders, psychosis and autism spectrum disorder, although most of the evidence is available for its use in anxiety disorders and PTSD. It is especially helpful for veterans and trauma survivors to process events by revisiting scenarios safely. Kimlinger observes, “Alongside AI, digital therapeutics and immersive tools such as VR are gaining traction in targeted, evidence-supported applications most often as complements to live care rather than replacements. These tools can support skill-building, stress management, or symptom relief between sessions and expand the range of ways individuals can engage based on preference. As interest grows in emerging or nontraditional modalities, including those receiving increased public attention, the strategic emphasis remains on clear clinical oversight, evidence-informed use, and thoughtful governance particularly in employer and workplace-related contexts where safety, trust, and appropriateness are essential.” XRHealth submits that VR treatment costs vary based on application, with specialized therapy sessions typically costing $200–$215 per session for trauma or anxiety, with specialized PTSD treatments in a similar range. A study has revealed that VRET has a reported success rate of between 66% and 90%. JULY 2026

Additional studies reported in Forbes show that VRET is an effective way to treat people experiencing depression, who may be reluctant to seek traditional therapy, and could be used as an alternative form of treatment to in-person therapy for people with social anxiety. Experts stress that a licensed therapist must be involved for it to be considered therapy. Innovation Must Continue Marc Augustin, a German psychiatrist and psychotherapist, warns that if text-based generative AI can increase the risk of some mental health problems, the rise of voice-based AI will be even worse. “The primary way humans communicate with AI is moving from typing and reading to speaking and listening. For most users, this will feel like a convenience. For vulnerable people — those prone to psychosis, mania, depression, or loneliness — it may represent a serious and unexamined risk,” Augustin writes.

Lyra Health’s State of Workforce Mental Health Report reveals a workforce navigating a paradox. While access to mental health support has improved, employees continue to struggle. Source: Lyra Health In the quest to improve access to care, many industry stakeholders are pointing to the value of Artificial Intelligence (AI). Generative AI tools are increasingly being used “offlabel” by employees for emotional support. While convenient, this trend introduces serious risks around data privacy, misinformation and clinical safety. However, it is important to consider a caveat that was recently issued from the American Medical Association (AMA) which is urging Congress to establish stronger safeguards for artificial intelligence (AI) in healthcare, warning that the rapid rise of mental health chatbots is outpacing the protections needed to keep patients safe. They warned that increased use, particularly in sensitive mental health settings, has exposed “gaps in oversight, with risks ranging from misinformation and emotional dependency to privacy breaches and, in some reported cases, chatbots providing harmful or inappropriate responses to users in distress.” Kimlinger expounds, “Across the field, the most responsible and impactful use of innovation, particularly AI is not about automating diagnosis or replacing clinicians, but about strengthening the human system of care. When designed thoughtfully, AI can reduce friction at multiple points in the journey: helping individuals engage earlier, helping care teams work more effectively, and helping organizations understand whether care is working. AIenabled intake and engagement tools can support clients in clearly articulating 52

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force multiplier extending capacity without diminishing quality.” Equally important is AI’s growing role in outcome measurement and learning. Lowburden, structured followup delivered at appropriate intervals can capture changes in symptoms, functioning, and experience over time, supporting a more measurement-informed approach to care.

Dani Kimlinger concerns, preferences, and areas of stress in ways that feel accessible and nonclinical, while also surfacing urgency or risk signals that inform timely routing and escalation. This improves the likelihood that a person’s first interaction with care is both fast and appropriate, rather than a false start that leads to disengagement.”

“When this data is used responsibly, it allows teams to adjust interventions when progress stalls and helps organizations identify patterns across populations, such as which approaches are most effective for specific needs or subgroups,” says Kimlinger. “This moves innovation beyond engagement metrics and toward meaningful insight about impact.”

Laura Carabello holds a degree in Journalism from the Newhouse School of Communications at Syracuse University, is a recognized expert in medical travel and is a widely published writer on healthcare issues. She is a Principal at CPR Strategic Marketing Communications. www.cpronline.com

AI can also play an important role behind the scenes by supporting not burdening staff. “Decisionsupport tools can help intake specialists, care coordinators, and clinicians quickly access relevant information, resources, and referral options in real time, reducing administrative load and cognitive fatigue. Intelligent workflows can streamline handoffs, flag missed followups, and prompt coordination across modalities, allowing staff to spend more time on judgment, relationship, and clinical work rather than navigation and documentation,” she remarks. “In the context of persistent workforce shortages, these kinds of efficiency gains function as a

Self-Funding Requires More Than Access. CRC Benefits partners with brokers to deliver self-funded solutions — bringing funding strategy, market insight, and ongoing account support to every case.

JULY 2026

EVOLVING FMLA LAWS – 2026 STATE ROUND-UP

Written By David Ostrowsky

n February 5, 1993, former President Bill Clinton signed the Family and Medical Leave Act (FMLA) into law during a ceremony in the Rose Garden in Washington, DC. It was nothing short of groundbreaking. In the ensuing decades, the FMLA would enable tens of millions of American employees to enjoy jobprotected 12-week leave to manage a wide range of personal situations, including the birth of a child, adoption or foster care placement, and medical care for either themselves or a relative. Employees were eligible for FMLA as long as they had worked for their employer for a minimum of 12 months, at least 1,250 hours over the prior 12 months, and worked at a location where the company employed at least 50 employees within 75 miles. While the legislation was truly monumental—new parents could now take time off from their jobs to bond with their infant children while other employees could put aside work to tend to ailing relatives—there was one problem: While U.S. workers were guaranteed their same position upon returning from FMLA, they were not compensated during the leave. Naturally, many employees, particularly those of limited financial means, have been unable to take full advantage of FMLA, or in some cases, have had to forego it entirely. However, the past decade has seen a groundswell of momentum among individual states pivoting towards paid FMLA programs. Currently, fourteen states and the District of Columbia have established comprehensive, mandatory state paid family leave programs. While every state has its own stipulations and unique eligibility periods, their respective programs are typically administered via a state-run social insurance fund, with premiums generated via required deductions on employee wages or employers paying a certain amount on the employee’s behalf. (The one exception is New York, which provides paid leave using a mandatory private insurance system whereby the state requires employers to purchase paid family and medical leave plans from a private insurance market where insurance companies, including the staterun New York Insurance Fund, offer coverage.) 54

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Mandatory programs require all covered employers in a state to participate, and all but one employs a social insurance policy design that funds these benefits through pooled payroll taxes on employees and/or employers. Meanwhile, nine states have adopted voluntary paid family leave programs whereby employers have the option to purchase a private insurance product to offer paid leave benefits to their workers, but they are not required to do so. Voluntary programs permit businesses to purchase a private insurance product to offer paid leave benefits to their workers, but they are not required to do so. Subsequently, access to benefits under voluntary programs depends on whether an employer has elected to participate. The movement of individual states providing greater protection for workers on medical leave has only intensified over the first half of 2026 as states such as Delaware, Maine, Minnesota, and Virginia have introduced new PFML (Paid Family Medical Leave) programs, while Colorado, Washington, and Rhode Island have bolstered current laws to further empower employees. Some of the highlights of those programs include: Delaware – Effective January 1, 2026, Delaware Paid Leave covers employers with 10 or more paid employees with payments made from insurance premiums. Delaware Paid Leave provides wagereplacement benefits to workers who need time away from their jobs due to a.) Medical Leave; b.) Family Caregiver Leave; c.) Parental Leave; and d.) Qualified Exigency Leave. **Under the Healthy Delaware Families Act, employers with 10-24 employees are only required to provide parental leave, while employers with 25 or more employees must provide full coverage. Maine – Effective May 1, 2026, Maine’s PFML program offers up to 12 weeks of paid time off for family leave, medical leave, leave to deal with the transition of a family member’s military deployment, or leave to stay safe after abuse or violence. Both employers and employees contribute to the paid family and medical leave fund. Minnesota – Effective January 1, 2026, the Minnesota Paid Leave Act provides most Minnesota workers with up to 12 weeks of paid time off per year, although expecting mothers can take up to 20 weeks, combining medical and bonding leave to recover and spend time with their newborn child. Claims for medical leave can include illness, injury, as well as mental health conditions and recovering from pregnancy. Bonding leave is available to both parents and doesn’t have to be taken at the same time, as long as the leave is taken before the child’s first birthday. Minnesota’s paid leave plan is funded by a payroll tax of 0.88 percent of employees’ wages, which is split evenly between employee and employer, though business owners can choose to cover more of the employee’s tax burden if they would like. Virginia – This past April, Virginia established a new PFML program that, beginning in 2028, will guarantee working Virginians have the right to take up to 12 weeks of paid time off for the following life events: caring for a child (birth, adoption, foster care); recovering from a serious health condition; caring for a family member recovering from a serious health condition; military family needs; and domestic violence, sexual assault or stalking. The program will be administered by the Virginia Employment Commission (VEC), and it will be funded by a small payroll contribution shared by covered employers and employees. Workers will be able to start taking leave and receiving benefits on December 1, 2028; employees and employers will start making contributions to the program on April 1, 2028. Colorado – Effective January 1, 2026, Colorado’s paid family and medical leave (FAMLI) program was amended to reduce the premiums and add an extra twelve weeks for employees who are parents of a child receiving inpatient treatment in neonatal intensive care. The FAMLI premium will be reduced from 0.9 percent of an employee’s wages to 0.88 percent for 2026. For 2027 and each year thereafter, the state’s FAMLI director will set the premium rate annually. Neonatal care coverage is in addition to other leave that may be available under FAMLI. However, neonatal care leave is limited to 12 weeks of leave per infant. JULY 2026

Washington – Effective January 1, 2026, Washington’s PFML Act underwent significant changes, particularly regarding the determination of when job protection applies. Some of the core changes included a.) reduced weekly claim minimum; b.) expanded job protection; and c.) FMLA stacking prevention. Rhode Island – Effective January 1, 2026, qualifying workers will be eligible for a full eight weeks of paid family leave (it had previously been seven weeks), with the income replacement calculated by a formula based on a worker’s highest quarter of earnings. Also, the wage replacement rate—how much workers are paid when they take leave—is currently at 60% of wages but will reportedly rise to 70% in 2027 and 75% in 2028. *** From a compliance perspective, employers, particularly those whose workforces spread across multiple states, now face a litany of new issues to monitor. After all, most of these paid family medical leave laws will apply even if an employer has just one employee working in a state with a PFML law. While of course every state’s program has unique characteristics, commonalities do exist among them. As such, the following overarching guidelines may be helpful for both employers and sponsors of self-funded health plans in navigating a new employment law landscape. • Employers need to recognize that they are responsible for notifying employees of their right to take leave. More specifically, once an employer receives a request for leave or becomes aware of a potential need for leave, the employer must advise the employee of their eligibility and the required procedures within five business days of the request. • Employers need to remember that employees get to elect whether they will take continuous or reduced-schedule leave, consistent with their medical needs and provided the employee and employer can reasonably agree on a schedule. • Employers need to ensure they properly manage how various state PFML laws exist alongside the federal FMLA statute and their internal paid time off (PTO) policies. • Employers with workers stationed in multiple states with different PFML laws need to remember that those respective laws could have different definitions of what constitutes “family,” contribution rates, and eligibility parameters, etc.

David Ostrowsky serves as the Manager of Corporate Communications for The Phia Group, a healthcare cost containment company headquartered in Canton, Massachusetts.

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AGENCIES PROPOSE NEW EXCEPTED BENEFIT OPTION FOR FERTILITY TREATMENT

Written By Alston & Bird Health Benefits Practice

n October 16, 2025, the Departments of Labor, Health and Human Services (HHS), and the Treasury (collectively, “the Departments”) jointly released Part 72 of Frequently Asked Questions (FAQs) regarding the implementation of certain provisions of the Affordable Care Act (ACA). These FAQs clarify how stand-alone fertility benefits can be structured under existing law and are part of a broader policy initiative first announced in Executive Order (“EO”) 14216, “Expanding Access to In Vitro Fertilization.” Among the EO’s recommendations was the issuance of regulations or guidance to allow employers to expand access to fertility coverage through excepted benefits. While the FAQs do not alter current law, a new proposed regulation published on May 13th (91 Fed Reg 27140) provides an additional excepted benefit coverage option for providing such benefits. The FAQ and proposed regulation provide an overview of a complex area of law involving four categories of coverage collectively referred to as “excepted benefits.” Excepted benefits generally do not have to comply with certain federal laws that typically apply to employer group health plans—most notably, the ACA’s market reform requirements—provided certain conditions are met. As noted in the FAQ, stand-alone fertility benefits can currently be offered through two of the four categories of excepted benefits without triggering ACA compliance requirements. The proposed regulation provides an additional option allowing fertility benefit coverage to be offered as a limited excepted benefit coverage under the same provisions (with slight modifications) applicable to vision and dental coverage. This is significant because, if finalized as proposed, employers would have an additional pathway for providing infertility benefits on either a fully-insured or self-funded basis, provided that certain requirements are satisfied. We explore each of these options below. 58

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EXPANDING LIMITED EXCEPTED BENEFIT COVERAGE -- TREATING FERTILITY BENEFITS MUCH LIKE STAND-ALONE VISION AND DENTAL COVERAGE

The proposed rule would allow fertility benefits to be offered as a limited excepted benefit coverage in much the same way that vision or dental coverage are offered. This means that the coverage must be provided under a separate policy, certificate, or contract of insurance or must otherwise not be an integral part of the plan. The agencies propose that eligibility for the fertility benefit be limited to individuals who are also eligible for coverage under the same employer plan sponsor’s group health plan. In addition:  Substantially all of the benefits must be for diagnosis, mitigation, or treatment of infertility or infertility-related reproductive health conditions and substantially all of which are provided by medical professionals authorized to practice under applicable law.  Benefits are capped at a combined lifetime maximum of up to $120,000 for the participant and their beneficiaries, indexed for inflation for plan years starting after 2028.  Employers must provide a notice that clearly describes the coverage and meets other specified requirements. The proposal includes three examples to illustrate these rules:  Example 1: An employer offers fertility counseling through a separate insurance policy. The coverage satisfies the proposed benefits and lifetime-dollar-limit requirements, and the issuer provides the required notice. The example concludes that the coverage qualifies as an excepted fertility benefit.  Example 2: An employer sponsors a regular group health plan and also offers self-funded fertility benefits for the mitigation or treatment of infertility; participants may enroll in either, both, or neither. The fertility benefit has the required lifetime dollar limit and notice. The example concludes the fertility benefit is not an integral part of the group health plan and qualifies as an excepted fertility benefit.  Example 3: An employer sponsors a self-funded fertility benefit plan that otherwise satisfies the scope, not-integral-part, and notice requirements, but in the following plan year pays benefits that exceed the inflation-adjusted lifetime dollar limit. The example concludes the plan fails to qualify as an excepted fertility benefit because it exceeds the permissible lifetime dollar cap, though excess fertility benefits could still be covered through the employer’s non-excepted group health plan if that plan otherwise complies with applicable requirements. Notably, the proposed rule does not define “infertility” and does not address conception issues facing same-sex couples. Although specific types of fertility benefits are not listed in the proposal to limit or define the broad category of benefits for “diagnosis, mitigation, or treatment of infertility or infertilityrelated reproductive health conditions,” the Departments are soliciting comments on the scope of excepted infertility benefits. As mentioned below in the EBHRA discussion, tax treatment for benefits that fall within this broad category is not always clear, and additional guidance would be welcomed. If finalized, the rule could apply to plan years beginning on or after January 1, 2027, and comments are also being sought on whether the rule could apply as early as the effective date (usually 60 days after a rule is finalized). Comments must be received no later than July 13, 2026. JULY 2026

FAQ Approach #1: Independent, Noncoordinated Excepted Benefits – An Insured Only Solution Independent, noncoordinated excepted benefits include coverage for only a specified disease or illness and hospital indemnity or other fixed indemnity insurance. Employers often offer stand-alone voluntary insurance coverage for a specified disease, such as cancer; similarly, they could offer coverage for fertility benefits. To qualify as an independent, noncoordinated excepted benefit, the following conditions must be met:  The benefit must be provided under a separate policy, certificate, or contract of insurance.  There must be no coordination between the provision of such benefits and any exclusion of benefits under any group health plan maintained by the same plan sponsor.  Benefits must be paid with respect to an event, regardless of whether benefits are provided under any group health plan maintained by the same plan sponsor. If these conditions are satisfied, an employer could offer a specified disease or illness policy covering infertility as an excepted benefit, regardless of whether the employee is enrolled in the employer’s traditional group medical plan. Unlike the excepted benefit coverage expansion under the proposed regulation, employees need not be eligible for the employer’s traditional ACA-compliant group health plan. Thus, for example, the benefit could be designed so that even part-time employees who are not eligible for the employer’s traditional group medical plan could enroll in the excepted benefit fertility coverage.

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It is important to note that fertility benefits offered through this exception cannot be self-funded by the employer. Unlike the proposed expanded limited excepted benefit coverage, which can be either fullyinsured or self-insured, independent, noncoordinated excepted benefits must be provided under a separate policy, certificate, or contract of insurance. Offering insured stand-alone coverage for fertility benefits may be costly, as individuals at higher risk for fertility challenges or with pre-existing conditions are more likely to purchase such coverage, increasing premium costs. However, if the adverse selection issues can be overcome, this coverage would be compatible with participation in a health savings account (HSA), since insurance for a specified disease or illness does not disqualify an individual from contributing to an HSA. FAQ Approach #2: Limited EBHRA Excepted Benefits Limited excepted benefits include, but are not limited to, certain types of health reimbursement arrangements (HRAs). Regulations specify that certain HRAs (and other account-based group health plans other than health flexible spending accounts) can qualify as limited excepted benefits if they meet specific conditions. These HRAs are known as excepted benefit HRAs, or “EBHRAs.” Conditions for EBHRAs:  The benefit must not be an integral part of the plan (other group health plan coverage must be available for the plan year).  Benefits are limited in amount (for 2025, the limit is $2,150).  No reimbursement of certain health insurance premiums (except for coverage consisting solely of excepted benefits).  Uniform availability to all similarly situated individuals, regardless of health factor. For employers who prefer to self-fund fertility benefits—even for employees not enrolled in an employer’s major medical group health plan—an EBHRA may be an option that would not be subject to other group health plan mandates like the ACA. However, with an annual maximum of just $2,150 in 2025, the cap is well below the cost of typical fertility treatments. By comparison, and not mentioned in these FAQs, an HRA integrated into the employer’s group health plan can provide unlimited, uncapped annual benefits. Although an integrated HRA would not be a stand-alone fertility benefit, it remains an option for employers wishing to self-fund a fertility benefit instead of offering it as a covered treatment or service under the major medical plan. Another drawback to an EBHRA (or even an integrated HRA) is that reimbursements for fertility expenses are limited to medical expenses as defined under Internal Revenue Code (“Code”) Section 213(d). Guidance and rulings in the area of fertility benefits have not kept pace with the lifestyles and expectations of would-be parents. For example, many women may expect coverage for egg storage, regardless of the length of storage, to be a 213(d) medical expense. However, there is uncertainty as to whether the expense would qualify if it is for undefined future conception rather than temporary storage necessary for immediate conception. Expenses related to surrogates are also not Code Section 213(d) medical expenses. Even fertility expenses for same-sex couples who may not meet a medical definition for “infertile” have not been formally addressed by the IRS in guidance applicable to all taxpayers. Clarification and expansion of 213(d) status to some of these expenses would be helpful for plan sponsors and plan participants alike. 62

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FAQ Approach #3: Employee Assistance Programs Limited excepted benefits also include, but are not limited to, employee assistance programs (EAPs). The FAQs remind employers that coaching and navigator services for fertility options can be provided through an EAP, as long as the EAP does not provide significant benefits in the nature of medical care and meets other regulatory requirements. However, if the EAP offers significant medical care benefits, it would not qualify as a limited excepted benefit. Additionally, the EAP must not be coordinated with another group health plan, must not require employee premiums or contributions, and must not have cost sharing. Key Takeaways for Plan Sponsors, Employers, and TPAs  Fertility Benefits as Excepted Benefits (FAQs): Employers may offer fertility benefits as independent, noncoordinated excepted benefits, as limited EBHRA excepted benefits or as limited excepted benefits, provided statutory and regulatory conditions are met.  Fertility Benefits as Limited Excepted Benefits (Proposed Regulation): This approach may be insured or self-funded, and operates much like the existing exceptions for vision/dental coverage. However, there is a proposed lifetime cap ($120,000) and only individuals eligible for the employer’s group health plan can participate.  Under the FAQ Approaches No Change to Current Law, But Benefits Limited: The FAQs clarify existing categories and conditions for excepted benefits. They do not change the law or create new obligations for plan sponsors, employers, or TPAs.

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JULY 2026

At-a-Glance Comparison Who can be eligible Insured/ self-funded Proposed new Only those eligible Insured or limited fertility for employer’s tradi- self-funded benefit tional major medical plan Independent Anyone, regardless Insured only non-coordinated of traditional plan excepted benefit eligibility EBHRA Only those eligible Self-funded for employer’s traditional major medical plan EAP Anyone, regardless Insured or of traditional plan self-funded eligibility

Coverage limitation

Impact on HSA eligibility

$120,000 lifetime cap for employee and beneficiaries

Unclear, may disqualify

Cap based on insurance policy

No impact

$2200 (2026) per year

May disqualify

Not significant medical care benefits. Must No impact coordinate with another group health plan, must not require employee contributions, and must not have cost sharing

Attorneys John Hickman, Ashley Gillihan, Amy Heppner, Laurie Kirkwood, and Michelle Jackson provide the answers in this column. John is partner in charge of the Health Benefits Practice with Alston & Bird, LLP, an Atlanta, New York, Los Angeles, Charlotte, Dallas and Washington, D.C. law firm. Ashley is a partner in the practice, and Amy, Laurie, and Michelle are senior members in the Health Benefits Practice. Answers are provided as general guidance on the subjects covered in the question and are not provided as legal advice to the questioner’s situation. Any legal issues should be reviewed by your legal counsel to apply the law to the particular facts of your situation. Readers are encouraged to send questions by E-MAIL to John at john. hickman@alston.com.

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NEWS

NEWS FROM SIIA MEMBERS JULY 2026 SIIA boasts a very active and dynamic membership. Here are some of the latest developments from member companies and individuals powering the self-insurance industry. VBA Taps Rick Ellsworth to Head Operations VBA, a leading provider of healthcare core administration software and technology solutions, announced that Rick Ellsworth has joined the company as Chief Operating Officer. According to a company statement, Rick brings deep expertise in healthcare technology, claims operations, and product leadership. He most recently served as General Manager of In-Network Products at Zelis, where he held full P&L responsibility for the Payer Compass product lines following its acquisition in 2022. JULY 2026

NEWS “Rick brings a strong track record of operational leadership and a deep understanding of the healthcare technology landscape,” said Daniel Laroue, CEO of VBA. “As we continue to invest in our team and expand our capabilities, Rick’s experience will be instrumental in helping us scale thoughtfully, strengthen our connection to our customers, and deliver the level of performance and service our clients expect.” In his role at VBA, Rick will oversee EDI and integration services, account management, and customer support. He will focus on strengthening operational execution, deepening alignment with customer needs, and ensuring VBA continues to deliver consistent, high-quality service as the company grows. His leadership will play a key role in helping VBA scale while maintaining its strong reputation as a customerfocused organization. IMA Completes Recapitalization IMA Financial Group of North America announced the completion of an equity recapitalization transaction. Oak Hill Capital and New Mountain Capital are each taking minority positions, with additional participation from HarbourVest Partners and a select group of prominent institutional co-investors.IMA employees will continue to own a majority of the Company, with 100% of associates participating as shareholders. SkyKnight Capital and The Stephens Group will exit in connection with the transaction. New Mountain will exit its existing position and reinvest alongside the broader investor group. “We accomplished every goal we set out to achieve: preserving majority employee ownership, maintaining our independence and strengthening our ability to build on what makes us successful — our talent, our future focus and people-first culture,” said IMA Financial Group Chairman and CEO Rob Cohen. “With the support of our investors, we will continue scaling our platform, expanding our expertise and investing in the people and partnerships that have fueled IMA’s growth.” Horizon Blue Cross of New Jersey Teams up with HealthEZ Horizon Blue Cross Blue Shield of New Jersey is entering the third-party administrator (TPA) market through HealthEZ, a Minnesota-based TPA that Horizon purchased last year. The move grants Horizon direct access to the self-funded employer market in New Jersey, with the insurer making new solutions available to businesses with 50 to 2,000 employees this summer for Jan. 1 effective dates. According to Becker’s Payer Issues, under the arrangement, HealthEZ will serve as the only TPA in New Jersey with access to Horizon’s provider network and stop-loss, dental, and vision products. Employers using HealthEZ will also have access to the BCBS national network, which includes more than 2 million providers. Jeff Sealey to Lead Stop-Loss Captive Division at Symetra Symetra Life Insurance Company announced the appointment of Jeff Sealey as vice president, Stop-Loss Captives. Jeff Sealey 66

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Rethink what’s possible with your stop-loss partner For over 40 years, Sun Life has been a trusted partner in risk management for self-funded employers. Now, we’re taking it further—combining proven cost savings with innovative health solutions that give your employees access to expert care when and where they need it most.

Clinical 360+: Optimizing care, maximizing value Our enhanced program builds on the industry-leading Clinical 360 foundation, which achieved over $68 million in savings in 2025. Available for select clients, this advancement adds personalized care pathways and expert navigation with the goal to deliver even greater value. Through proactive outreach and dedicated support, your employees gain seamless access to specialized programs, digital health tools, and clinical guidance—all designed to improve health outcomes while managing costs effectively.

It’s time to reconsider what you expect from your stop-loss partner. Let Sun Life support your business with innovative health solutions that prioritize access to quality care.* Ask your Sun Life Stop-Loss Specialist about Clinical 360+ today.

*Hinge Health will be provided to eligible members at Sun Life’s expense through the ﬁrst policy year. Sun Life is not responsible or liable for the care, services, or advice provided by Somatus, OptiMed Health Partners, or Hinge Health, and reserves the right to discontinue this service at any time. Sun Life will collaborate with your TPA on eligibility and applicability of programs. Health Navigator is provided by PinnacleCare. PinnacleCare is a member of the Sun Life Financial Inc. (“Sun Life”) family of companies. PinnacleCare and its employees do not diagnose medical conditions, recommend treatment options or provide medical care, and any information or services provided should not be considered medical advice. Any medical decisions should be made only after consultation with and at the direction of the member’s medical provider. Any person or entity who provides health care services following a referral or other service provided does so independently and not as an agent or representative of PinnacleCare. Group stop-loss insurance policies are underwritten by Sun Life Assurance Company of Canada (Wellesley Hills, MA) in all states, except New York, under Policy Form Series 07-SL REV 7-12 and 22-SL. In New York, Group stop-loss insurance policies are underwritten by Sun Life and Health Insurance Company (U.S.) (Lansing, MI) under Policy Form Series 07-NYSL REV 7-12 and 22-NYSL. Policy offerings may not be available in all states and may vary due to state laws and regulations. Not approved for use in New Mexico. © 2026 Sun Life Assurance Company of Canada, Wellesley Hills, MA 02481. All rights reserved. The Sun Life name and logo are registered trademarks of Sun Life Assurance Company of Canada. Visit us at www.sunlife.com/us. BRAD-6503-ad #1293927791 11/24 (exp. 11/26)

NEWS In this new role, Mr. Sealey will lead the strategic development and growth of Symetra’s captive solutions, expanding the company’s capabilities to meet the evolving needs of clients and partners. With deep expertise in alternative risk financing, he will play a key role in advancing Symetra’s commitment to delivering flexible, client-focused risk solutions. “We are delighted to welcome Jeff Sealey to the stop-loss team,” said Jeremy Freestone, senior vice president, Stop-Loss Business Strategy. “Jeff brings a diverse background spanning U.S. Navy service, commercial finance, and more than a decade in the health insurance industry. Since transitioning into healthcare in 2009, he has partnered with employers to navigate complex funding decisions, including onsite and near-site employer clinic evaluation and group stop-loss captive strategies designed to help stabilize self-funded risk.” Mr. Sealey joins Symetra from Crumdale Specialty, where, as vice president of stop-loss sales, he led the nationwide team responsible for the distribution of self-funded products and PBM solutions. Lockton Names New Leader for its Alternative Risk Solutions Practice Lockton has appointed Ashleigh Sears as Alternative Risk Solutions Practice Leader, charging her with the strategic direction of the brokerage's US alternative risk team. Sears leads a team of finance, accounting and credit specialists who design programs aligned to clients' risk financing and insurance needs. The practice covers captive consulting, parametric insurance,

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NEWS structured risk solutions, fronting arrangements, alternative collateral strategies and other customized program structures. She joins from Everest, where she was head of alternative risk and national accounts excess casualty. Before Everest, Sears was head of casualty at USQ Risk, overseeing the development and execution of structured and alternative risk transfer solutions in the casualty sector. Kimberly Kline Promoted to CRO at MedWatch MedWatch, a leader in medical management services, announced the promotion of Kimberly Kline to Chief Revenue Officer (CRO). In this role, Kline will lead MedWatch’s enterprise revenue strategy, overseeing sales, account management, and marketing to enable coordinated growth and enhance the client experience. Kimberly Kline

Kline joined MedWatch in 2012 and has played a key role in the company’s evolution, most recently serving as Vice President, Client Success & Strategic Initiatives. Throughout her tenure at MedWatch, Kline has played a critical role in strategic initiatives that have significantly strengthened partnerships and elevated MedWatch’s reputation as a trusted, results-driven solutions provider. She is most proud of her contributions to the company’s development of innovative programs, including a best-in-class concierge model that has put MedWatch at the forefront of enhancing the member experience and elevating its impact on clinical outcomes while delivering measurable value to clients. “Kim has a proven ability to turn strategy into execution and deliver meaningful results for our clients and our organization,” said Sally-Ann Polson, MedWatch President & CEO. “Her leadership will be instrumental as we continue to scale our commercial operations and strengthen our position in the health cost containment market.” HMIG Names New Regional Vice President HM Insurance Group (HMIG) has named Vic Parker, regional sales vice president, Mid-Atlantic and Northeast Regions, replacing Carolyn Coleman, who will retire in July 2026 after 12 years of service to the company. In this role, Parker will be responsible for the Atlanta, Charlotte, Philadelphia, Pittsburgh, New England, New York, and Washington, D.C., territories. He has been with HM since 2014 when he joined the company as an account manager for the Syracuse Regional Sales Office. Tim Kessler Named President at RxBenefits

Victor Parker

RxBenefits announced Tim Kessler has joined the company as President. His appointment reflects RxBenefits' continued focus on helping benefits advisors and self-funded employers manage pharmacy benefits costs through stronger technology, deeper data insights, and innovation while providing exceptional member care.

JULY 2026

NEWS Kessler brings more than 20 years of leadership across healthcare operations, product, information technology, and project management. He joins RxBenefits from TurningPoint Healthcare Solutions, where he served as Chief Operating Officer and previously held senior operations and technology leadership roles.

Tim Kessler

"As the pharmacy benefits space shifts rapidly, we're committed to bringing clients new tools, data, and technology to help them stay ahead," said Robert Gamble, CEO of RxBenefits. "Tim's experience leading technology transformation and building solutions that address real-world needs stands out. By welcoming him as President, we're strengthening our promise to help advisors and employers make smarter decisions, respond to change faster, and set a new direction for innovation."

W H AT U M E B R I N G S TO T H E TA B L E UNDERWRITING M A N AG E M E N T EXPERTS

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Flexible Program Design

Risk Protection That Scales

Disciplined Underwriting

Multiple Funding Pathways

Optione built to align with diferent plan etructuree, funding approachee, and organizational goales

An experienced, coneietent underwriting approach focueed on reliable outcomee and predictable performances

Coverage etructured to adjuet ae plan eize, utilization, and riek proflee changes

Traditional, levelfunded, and alternative etructuree deeigned to eupport a range of beneft etrategiees

Support at Every Stage

Guidance throughout the lifecycle of the plan, from initial underwriting through renewals

Group health solutions from a carrier you can trust Nationwide® is a strong and stable FORTUNE 100 company with resources to help employers manage their self-insured plans. Our specialists are ready to help your customers stay ahead of rising health care costs. Why work with Nationwide? •

More than 20 years of trusted stop-loss solutions

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Comprehensive and innovative Self-Funded Program and stand-alone stop-loss solutions

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Flexible plan designs to meet employer and agent needs

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Access to national networks or reference-based pricing

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Supporting employer groups from 2 to 5,000+ members

Visit nationwide.com/grouphealth to learn more. Plan availability varies by state. Ask your sales representative for more information. Plans are underwritten by Nationwide Life Insurance Company, Columbus, OH 43215. CA COA #7032. In Hawaii, Louisiana and Oregon, plans are underwritten by Nationwide Mutual Insurance Company, Columbus, OH 43215. Nationwide, the Nationwide N and Eagle, Nationwide Employee Benefits and Nationwide Provide are service marks of Nationwide Mutual Insurance Company. © 2025 Nationwide NSM-0630AO (10/25)

2026 SELF-INSURANCE INSTITUTE OF AMERICA BOARD OF DIRECTORS CHAIRWOMAN OF THE BOARD*

BOARD MEMBER

Amy Gasbarro President ELMCRx Solutions

John Fries Head Accident & Health NA Swiss Re Corporate Solutions

CHAIRPERSON ELECT,

BOARD MEMBER

TREASURER AND CORPORATE SECRETARY*

Mark Lawrence President HM Insurance Group BOARD MEMBER

Blake Allison Chief Executive Officer Employers Health Network

Matthew Smith Managing Director Risk Strategies BOARD MEMBER

Beth Turbitt Managing Director Aon Re, Inc. VOLUNTEER COMMITTEE CHAIRS

BOARD MEMBER

Captive Insurance Committee George M. Belokas, FCAS, MAAA President Beyond Risk

BOARD MEMBER

Future Leaders Committee Morgan Sandell Operations Lead, Underwriting Operations QBE North America

BOARD MEMBER

Price Transparency Committee Traci McGinnis Founder & Principal Datavoce Consulting, LLC

Christine Cooper CEO aequum, LLC

Orlo “Spike” Dietrich Operating Partner Ansley Capital Group

Jeffrey Fitzgerald Managing Director, SRS Benefit Partners Strategic Risk Solutions, Inc.

Cell and Gene Task Force Ashley Hume President Emerging Therapy Solutions® * Also serves as Director

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SIIA NEW MEMBERS SILVER MEMBERS:

CORPORATE MEMBERS:

Richard Corbin CEO/Founder Self Fund Platforms, Inc. Libertyville, IL

Sonya Cecil VP Claims Administration Ascension/ABS Troy, MI

Mary Kurapkat Senior Director, Sales | East VIVIO Health, Inc. Hayward, CA

Joseph Chandler CEO Rima New York, NY

Michael Techtmann Partner SLATE Doylestown, PA

Harry Fast VP, Director of Reinsurance, VBHS Alliant Insurance Services, Inc. New York, NJ Vasil Hlinka Managing Partner TechPath Advisors Media, PA

Kristie Kalenka Managing Director Kohlberg Mount Kisco, NY Keith Miller VP/CFO Oxford Construction Company Albany, GA Ray O’Neel Director PBM Performance RxConnection Atlanta, GA Harindra Sebastian National Chief Health Actuary Alera Group, Inc. Deerfield, IL Melissa Thomas Director AllianceBernstein Austin, TX Joël Thompson President AuclairRe International, Inc. Bennington, VT

JULY 2026

2026 BOARD OF DIRECTORS Dani Kimlinger CEO & Partner MINES & Associates

Liz Midtlien Head of Large Claims Solutions BCS Financial Corporation

Jonathan Socko President East Coast Underwriters, LLC

Les Boughner Chairman Advantage Insurance

Matt Hayward Office President Ryan Specialty

Nigel Wallbank SIEF Chairman Emeritus

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IDR doesn’t have to be the first stop Zelis helps TPAs take a more proactive approach to NSA claims, with pricing and resolution strategies designed to support better outcomes earlier.

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Predictability happens when expertise leads. Managing uncertainty through a range of insights. At HM Insurance Group, experts guide every decision. Our experienced minds bring together curated data, clinical analysis and disciplined underwriting to help manage complex risk and deliver the right Stop Loss coverage at the right price. It’s a reliable method our brokers stand behind — in a market that’s anything but predictable. Experience predictability in practice. Visit hmig.com/predictability.

Stop Loss coverage may be underwritten by HM Life Insurance Company, Pittsburgh, PA; HM Life Insurance Company of New York, New York, NY; or Bridge City Insurance Company, Pittsburgh, PA, under policy form series HMP-SL (08/19), HMP-SL (06/20), or BCICP-SL (06/20) or similar. The coverage requested may not be available in all states and is subject to individual state approval. In Oregon, Bridge City Insurance Company does business as BCIC Insurance Company. MX6416682 (5/26)