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High-Cost Claims

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TABLE OF CONTENTS

NOVEMBER 2026 VOL 216

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

F E AT U R E S 4

TPAS TACKLE HIGH-COST CLAIMS Written By Laura Carabello

BEHAVIORAL HEALTH’S AI BALANCING ACT

Written By Bruce Shutan

ARTICLES 36

EMERGING HEALTH PLAN COST REALITIES FOR NEWBORN & EARLY CHILDHOOD CARE

Written By Laura Carabello

AI AND HEALTH PLANS: THE BEST OF TIMES, THE WORST OF TIMES Written By Jeannie Comins-Roberts

THINKING OUTSIDE THE OPEN ENROLLMENT BOX

MEMBER NEWS

Written By Bruce Shutan

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

NOVEMBER 2026

F E AT U R E

TPAs Tackle

High-Cost Claims

W W

hen a single claim can eclipse six or seven figures, self-insured employers don't have the luxury of finding out after the fact. High-cost claims, from complex cancer treatments and rare disease therapies to catastrophic injuries, are rising in both frequency and severity, and they're reshaping how plan sponsors think about risk. The scale of this challenge is downright jarring as employers face another tough year. Aon projects employer health casts to increase 9.5% next year to more than $19,000 per employee. According to WTW's 2025 Best Practices in Healthcare Survey, what once qualified as a "high-cost" claim at $50,000 now often starts at $100,000, with multimillion-dollar claims increasingly common, driven by advanced treatments like gene therapy or complex conditions such as congenital disorders and transplants.

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Written By Laura Carabello

High Cost Claims Analysts state that just 5% of members drive 56% of total healthcare spending, with the top 1% alone responsible for 28% of costs, as 5% of members account for 56% of total spending, while just 1% are responsible for 28% of the costs. Claims exceeding $1 million have grown even more dramatically, with QBE North America's 2026 Accident & Health Market Report finding that the frequency of million-dollar claims has nearly tripled over the past five years, with average severity in 2025 running 10% above prior-year averages. Cancer remains the single largest driver, followed by nervous system diseases and newborn care. •

Tumors alone account for 31% to 36% of stop-loss claim reimbursements across all years studied

•

Blood cancers carry an outsized share of that burden at a $1 million deductible threshold, with peremployee monthly costs for blood cancers rising more than 70% in 2025.

•

Hematologic malignancies represent more than half of all neoplasm claims

For third-party administrators (TPAs), this isn't simply a claims processing challenge. It’s a real-world test of whether they can move from reactive administration to proactive cost containment. The TPAs winning this battle aren't the ones with the fastest turnaround times (although that’s important!); they're the ones catching high-cost claims before they spiral, armed with data, clinical insight and negotiation strategies that protect both the plan and the patient. As employers challenge broad assumptions about savings and pose more difficult pharmacy benefit questions, TPAs must be prepared to provide greater understanding of exactly what their clients are paying for, where dollars are being spent and how to realistically change the results. Lori Daugherty, CEO, RxLogic, says, “TPAs are under tremendous pressure to respond to these issues, especially when there is a PBM involved that Lori Daugherty really controls the pharmacy model. That is why TPAs need a partner with independent technology that can help them take more ownership of pharmacy operations and provide a transparent picture of the pharmacy spend, rebate structure, utilization patterns and plan performance. This also impacts formulary and clinical decisions, enabling TPAs to influence pharmacy cost and member experience, such as introducing programs like prescription drug discount cards.” As TPAs shift the pharmacy focus from an administrative obligation to a business growth strategy, Daugherty explains that they may already be managing several aspects of pharmacy operations – managing enrollment, answering inquiries, fulfilling data reports and demystifying pharmacy benefit manager (PBM) operations for employers. "Taking control of pharmacy benefits shifts the TPA business model,” she explains. “Rather than treating pharmacy as a standard vendor pass-through, TPAs build a branded solution. This helps employer clients, strengthens broker ties, and unlocks pharmacy administration revenue. Reshaping the pharmacy benefit model turns a simple vendor relationship into a branded TPA asset.” Standing-out in the self-insured market has become a priority for TPAs that seek a unique edge to stand out from competitors. NOVEMBER 2026

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High Cost Claims “Saving money for clients is now a major way to win business,” she adds. “Brokers and employers want more than basic claims processing -- they want a strategic partner who can lower costs and improve health results. That’s the value of an independent technology platform and a key ingredient of the RxLogic value proposition.” Jason Hines, CEO and co-founder, Gigasheet, a price intelligence platform, observes, “TPAs abilities in managing high-cost claims vary widely. We work with a number of different organizations that use hospital and payer price transparency data to identify claims that are outside norms and provide evidence of market rates for negotiations.” Hines sees some TPAs beginning to incorporate this data into payment integrity, repricing, and complex claims workflows, noting, “But anecdotally, adoption still appears limited. There is also a need for greater transparency around percentage-of-savings fees.” He suspects that savings baselines can be inflated or difficult to verify, adding, “This can make a large fee look justified even when the final price is still above a fair market rate.” That makes it harder for employers to understand their actual savings and whether the intervention delivered a good value.” WHAT’S WORKING

TPAs are making strides in tackling high-cost claims using price transparency data to re-imagine Reference-Based Pricing (RBP), Out-ofNetwork (OON) negotiations and member navigation inside networks.

Phil LeFevre

Phil LeFevre, vice president, Business Development, Denniston Data Inc. (DDI), says his clients are leveraging both market reimbursement data (across all payers and providers), as well as line-level pricing by NPI and payer. “The biggest shift is away from Medicare multiples (1.4x Medicare) to a MLCR (pronounced "Mil-Sir"), the Median Local Commercial Reimbursement,” he explains. “MLCR is slightly higher than 1.4x Medicare (~1.75x) but fluctuates by market and procedure to reflect a fair and defensible reimbursement amount, just as intended by the No Surprises Act for the Qualifying Payment Amount (QPA).” LeFevre maintains that this makes negotiations much easier, improves access and reduces disputes and balance billing, adding, “We are also helping TPAs surface NPI level network rates combined with provider quality data to leverage massive opportunities in their own network to optimize for low cost and high quality – anomalies that should not exist in most markets but are ample in all the big healthcare networks. By surfacing these opportunities using Smart Scores through tiering, steering or a member shopping experience, TPAs are creating big savings for employers while protecting their roles as fiduciaries.” Strong TPAs should be leveraging claims editing software prior to processing a claim, looking for errors in the bill, upcoding and unbundling. Todd Martin NOVEMBER 2026

High Cost Claims That’s the recommendation of Todd Martin, chief sales officer, Nova Health, saying, “In addition, TPAs with in-house medical management programs allow for early detection of potential high-cost claimants at which time the member can be engaged with a nurse to help navigate the most cost-effective and quality care. Once someone has a high dollar claim, there should be Case Management support to help with the transition of care, treatment plan compliance and gaps in care.” He points to a recent example from Nova’s medical management team which conducted a transplant contract review for a member. “As a TPA, Nova conducts transplant contract comparisons to get the employer the best rate across multiple vendors, rather than just using network rates,” he explains. “Some clients with ASO models don’t realize they can go outside the network -- but a TPA can do so and achieve cost savings.” Moreover, in a PPO network arrangement, there can often be restrictions on the ability to audit claims, as they could be providing the TPA with a simple repriced claims file without the ability to see a lot of detail surrounding the claim. “Itemized bills can be requested from the provider or facility, but this is often challenging to succeed,” continues. “There is definitely a large transition amongst many employers to a Reference Based Pricing model as many of the BUCA solutions are just no longer sustainable. Some employers are doing this in lieu of a network 100% or just transitioning out-of-network claims to this form of reimbursement.” Interventions, especially early on, are helping to improve outcomes, which ultimately help reduce the cost of the claims. “Early detection and guidance can help conditions be managed before they turn into a high dollar situation,” he adds. “Managing gaps in care and supporting with treatment plan performance will ultimately reduce admissions, in-patient stays and readmissions for non-compliance.” Ultimately, the TPA should be a partner to the consultant and employer. “TPAs work with many point solutions, and we have the experience of seeing what works and what doesn’t work,” he avers. “When TPAs identify point solutions that can control cost with payment integrity packed with improved outcomes, it makes for a strong partnership and more long-term clients.”

Jakki Lynch

Jakki Lynch, RN, CCM, CMAS, CCFA, director, Cost Containment, Carbon Stop Loss Solutions, underscores that while interventions can mitigate the financial impact of catastrophic medical events, they cannot prevent the events themselves. “They can help identify, manage, and potentially reduce the cost of high-dollar claims such as cancer, major trauma, organ transplants, premature neonates, extended hospital stays resulting from hospitalacquired events, and other complex or catastrophic conditions,” says Lynch. “However, these events may still occur regardless of the cost-containment strategy. Therefore, these interventions should be viewed as financial risk-mitigation tools that help preserve plan resources and minimize excessive or avoidable spending—not as mechanisms that eliminate catastrophic medical risk.” 8

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High Cost Claims

Jim Carlson, VP and head of Business Development, Self-Funded, Evidium, attests that complex claims management, reference-based pricing and aggressive out-of-network negotiation all do real work, but they're triggered by a claim that's already in motion. “By the time a TPA is negotiating a six or seven-figure oncology or gene therapy claim, the cost trajectory was largely set months earlier,” he says, emphasizing that most tools available to TPAs today only offer a claims-based risk score, which tells you what happened, not why or what's coming next. “Evidium models each member's actual clinical journey, so plan sponsors get real visibility into emerging high-cost conditions before they escalate, and underwriting teams get sharper stop-loss precision going into renewal,” says Carlson. “Every insight that is generated is explainable and auditable, not a number without reasoning behind it, which matters when a plan sponsor has to defend a fiduciary decision.” Carlson adds that kind of clinical grounding is exactly what specialty drug management, re-pricing and chronic condition programs need to be effective. “On fees, plan sponsors need to look closely at percentage-ofsavings arrangements,” he advises. “If a vendor's compensation rises when claims costs rise, that's worth scrutinizing before assuming it's aligned with cost containment." There is room for improvement in complex claims management, Source: 2026 Triple Tree, LLC concedes Lynch. “Reference-based pricing and aggressive negotiations with out-of-network providers are a good start, but if the underlying bill contains inappropriate or erroneous charges, negotiating a discount off the billed amount may not capture the full value available. The key is selecting a payment integrity partner that thoroughly reviews the bill and medical record, identifies unsupported or inappropriate charges, ties findings to regulatory and plan requirements, and develops creative, provider-acceptable solutions.” She says it is also optimal to partner closely with the reinsurer, given its exposure to a high volume of complex claims and its expertise in identifying effective solutions. “Combining the reinsurer’s insights with strong clinical, claims, and payment integrity expertise can ensure the claim is accurately evaluated, and negotiations begin from the right starting point,” says Lynch. High-cost claims are not always the result of catastrophic medical events alone. Larry Castle, director, Clearinghouse Operations, Smart Data Solutions, contends, “They are often amplified by administrative friction that delays intervention, obscures emerging risks, and limits visibility 10

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High Cost Claims into cost drivers. Fragmented data across eligibility, claims, medical records, prior authorization, and payment workflows makes it difficult for TPAs and employers to identify issues early enough to influence outcomes.” He says the most effective TPAs are adopting data-driven strategies that aggregate and normalize information across the healthcare ecosystem, enabling earlier detection of high-risk cases, stronger payment integrity controls, improved specialty drug oversight, and more informed reimbursement decisions. These capabilities help employers better protect plan assets while improving member experiences and health outcomes. “At Smart Data Solutions, we see firsthand how improved data accessibility and workflow efficiency help TPAs gain greater visibility into emerging risks and cost drivers,” Castle adds. “As healthcare costs continue to rise, reducing administrative friction, increasing transparency, and providing a clearer understanding of how savings are generated will be critical to helping employers manage high-cost claims and build a more sustainable healthcare ecosystem.” Larry Castle

TPAS PROVIDE COMMUNICATIONS, GUIDANCE AND RESOURCES

For the sake of positioning themselves well in a very competitive industry and providing optimal value to self-insured employers, TPAs can certainly generate guidance and resources for specialty drug management, re-pricing, payment integrity and chronic condition management. David Ostrowsky “In terms of specialty drug management, it’s no secret that highly specialized medications account for a massive portion of a given employer’s total healthcare spending,” attests David Ostrowsky, manager, Corporate Communications, The Phia Group, LLC. “Regarding re-pricing, many TPAs have the background and experience to offer guidance on reference-based pricing models that some self-funded plans may otherwise be unfamiliar with. And lastly, for chronic condition management, many self-funded plans do have a very small number of members who suffer from chronic—and often severe—illnesses that prove to be massive cost drivers. Subsequently, many TPAs are able to introduce digital health tools and AI-driven analytics that self-funded plans can adopt for such members to use.” VALUE OF COLLABORATION

In the self-funded world, cost containment is the risk management tool employers feel directly. For a smaller group, one member on novel cancer therapies can outpace a quarter’s financial planning. Mitigating that risk requires TPA and stop-loss partners aligned on the plan’s financial goals and open with information, then bringing the employer, TPA, and carrier together at the outset of a complex claim. Early collaboration helps manage high-cost claims and protect self-funded plans from unexpected exposure,” says Tanya Arrowsmith, senior vice president, A&H, Crum & Forster. “Engaging the stop-loss carrier at inception allows the parties to align strategy, evaluate cost-containment opportunities, obtain documentation, and present a unified position in provider negotiations. This supports timely, favorable outcomes while protecting plan assets and stop-loss reimbursement.” 12

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High Cost Claims She says the impact reaches renewal. Proactive cost management clarifies claim experience and future exposure, supporting informed underwriting and competitive stop-loss pricing.

Tanya Arrowsmith

“Coordination among the employer, TPA, and stop-loss carrier is especially important when managing out-of-network claims,” continues Arrowsmith. “In August, the Fifth Circuit struck down parts of the No Surprises Act rules governing QPA calculations. Although existing QPAs may remain temporarily, recalculation may create uncertainty for plan forecasting and compound exposure in federal IDR. Bringing all three parties together early in the claim offers the best opportunity for a collaborative, timely resolution.”

TURNING METABOLIC HEALTH INTO A PROACTIVE TPA STRATEGY

The metabolic health crisis has reached a tipping point, fueling a healthcare crisis that directly threatens employer bottom lines through skyrocketing claims and lost productivity. TPA’s now have a tremendous opportunity to work with employers to change this paradigm. Diabetes, cardiovascular disease, and cancer rank among the top 5 highest claims and are driven by poor metabolic health. Containing these costs requires a proactive approach—one prioritizing early detection and targeted intervention to deliver better clinical outcomes, substantial savings, and a resilient workforce.

NOVEMBER 2026

High Cost Claims This metabolic crisis hits hardest in the liver, where silent disease is rapidly accelerating one of the most expensive threats to workforce productivity. Metabolic dysfunction-associated steatotic liver disease (MASLD) and its progressive form, MASH (steatohepatitis), affect an estimated 1 in 3 adults—most undiagnosed. Left unchecked, MASLD silently progresses to cardiovascular disease, diabetes, cirrhosis, and some cancers, driving high-cost claims. For TPAs, this is a chance to differentiate: proactively packaging early detection into the programs you bring clients, rather than waiting for costs to surface downstream. “The issue isn't lack of concern—it's lack of early visibility,” says Shawn McGinnis, director, Employer Markets, Echosens. “Non-invasive point-of-care liver health screening using FibroScan® for risk stratification can change that equation by identifying liver fat and stiffness before disease progression.” She says we need to prioritize programs that address whole-person health, not treat one disease at a time in a silo, adding, "Early detection through preventive screening is the best way to catch disease before it progresses to a higher, more costly disease burden.” Deployed in onsite clinics, employer screening events, or other direct primary care settings, rapid risk stratification enables care teams to apply timely, cost-effective interventions, including smarter utilization of advanced therapies. TPAs can help employers generate positive outcomes: 



Lower Costs: o

Reduce ER visits and admissions

Avoid unnecessary specialist referrals and advanced imaging

Strategically deploy pharmacy interventions

Delay or reverse costly disease progression – diabetes, CVD, cirrhosis, and certain cancers

Mitigate catastrophic stop-loss claims

Streamline Care: o



Primary care manages early disease - avoiding unnecessary referrals to specialists

Boost Productivity: Reduce employee absenteeism, presenteeism, and turnover

Targeting and treating isolated conditions isn't enough. For TPAs, bringing this kind of proactive screening to clients gives employers a viable tool to bridge the metabolic health gap before it escalates. McGinnis shares, “This is a tangible way for TPAs to bring value to clients by providing better outcomes while reducing costs.” DATA ACCESS MATTERS

TPAs that are actually managing the health plan spend are paying closer attention to data access. The alarm sounded when the National Alliance of Healthcare Purchaser Coalitions recently released its 2026 Pulse of the Purchaser survey revealing that employers with complete claim-level access to their medical data are running an average of 11.9 high-value purchasing strategies. 14

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High Cost Claims Employers without that access are running 7.9, a significant difference driven entirely by whether the employer can see what is happening inside its own plan. Across all 26 hospital and high-cost claim strategies measured in the survey, employers with complete claims data were more likely to be taking action. Access is necessary but not sufficient, as employers also need the operational support to translate claims intelligence into purchasing decisions. Roughly one in three employers in the survey report they do not have complete claim-level access to their medical data, and only about three in five are confident they can audit their own complete files. According to Asad Shoostry, chief technology officer, AscellaHealth, “Access to claims data is only the first step. For increasingly complex treatments, the real challenge is connecting medical and pharmacy data that may arrive at different times, through different systems, and under different billing structures. Employers need an integrated, longitudinal view that can match those events together and turn fragmented claims into actionable insight; otherwise, having the data does not necessarily mean you can use it to make better purchasing or benefit decisions.” It also appears that where the data is stored matters: three-quarters of employers keep claims with their health plan or TPA, and that group reports the lowest access rates. Employers using an independent data warehouse report access rates above 84%. TPAs are paying attention since the real implication is straightforward: If the self-insured health plan claims data resides inside the same TPA vendor relationship that is being evaluated, the plan is less likely to have unrestricted access to it. Without access, taking action is a challenge.

NOVEMBER 2026

High Cost Claims TPAS AND PHARMACY

TPAs have an opportunity to play a larger role in pharmacy and help their employer clients achieve greater transparency, better cost control, and a more connected benefits experience. For many self-insured employers, pharmacy benefit operations have moved from a line-item to a C-suite level concern. As costs increase and specialty drugs – including GLP1s – create new risk, plan sponsors are asking harder questions about transparency, PBM rebates and data access. This often puts TPAs in a difficult position as they are typically the first call when an employer wants explanations and answers. However, the pharmacy benefit may still sit with a separate PBM partner that controls key parts of the economics, reporting, and member experience. TPAs are becoming more accountable, taking on some responsibility for whether the pharmacy benefit is delivering value. This level of accountability avoids surprises when the spend keeps rising, and the system just keeps getting renewed. Closing these gaps creates a new opportunity for TPAs to start taking more ownership of the pharmacy benefit. This does not mean they need to immediately become a full-service PBM, but it should trigger them to build or private-label PBM capabilities that give them real control and flexibility over margin, data and clinical strategy. "The most effective TPAs are no longer treating high-cost drug claims as a back-end problem,” says Jake Velie, CPT, chairman & CEO, National Integrative Health (NIH). “They're integrating specialized pharmacy strategy directly into the pre-certification/prior authorization/case management process, so that by the time a specialty, orphan, REMS-restricted, or infusion therapy is approved, the lowest-net-cost sourcing, site-of-care optimization and clinical alternatives have already been explored.” He stresses that TPAs don't have to wait to build out a full integration. “Single case agreements on active high-cost claimants offer an immediate path to savings and give plan sponsors tangible results they can see right away,” he explains. “Those already taking this approach are seeing meaningful reductions in plan spend and improved stop-loss renewal performance. When paired with cost-plus fee transparency rather than percentage-of-savings arrangements, this upstream approach to high-cost Rx is quickly becoming what distinguishes the TPAs winning new business from those standing still." Johanna van Nijkerk, vice president of business development, AscellaHealth who has worked on the plan sponsor side, observes that the specialty drug pipeline represents one of the most significant financial threats facing health plans and employers today. “As more high-cost therapies enter the market, organizations can no longer rely on traditional approaches to manage spend,” says van Nijkerk. “Success depends upon having the visibility, clinical expertise, and proactive management strategies needed to control costs while preserving patient access." She offers this cautionary advice: “I've seen specialty drug management evolve into a significant fiduciary and compliance challenge. Organizations are increasingly expected to justify not only what they spend, but also how those decisions are made. Without transparency, oversight, and accountability, they face growing financial, regulatory and reputational risk."

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High Cost Claims GLP1 COVERAGE CHALLENGES

Leaders at the Business Group on Health attest that GLP-1s have been a significant factor in that affordability equation, and for many employers, they're having to make some hard decisions about maintaining the viability of their overall plan and whether or not they can do so while still continuing GLP-1s. Dr. Bruce Roffe, Registered Pharmacist, president and CEO, H.H.C. Group offers solid recommendations for managing GLP1 utilization, saying TPAs can help health plans to avoid crude coverage restrictions alone and instead use a combination of eligibility controls, outcomes management and contracting. “The plans that are most successful are generally trying to ensure GLP1s are used for the highest-value members while limiting long-term use among members who are not achieving meaningful clinical benefit,” says Roffe. “For example, TPAs can support their clients by recommending tight prior authorization criteria that require FDA-labeled BMI criteria, documentation of obesity-related comorbidities, participation in a structured weight management program, failure of lifestyle intervention for a defined period and prescribing by or consultation with appropriate providers.” Bruce Roffe

Given his interaction with TPAs across the country to achieve optimal cost containment through cost management initiatives, Roffe observes that many are suggesting participation in a weight management program as well as continuation criteria. “The latter may be the single biggest opportunity, with the recommendation to approve treatment initially for 3-6 months and then require evidence of meaningful weight loss (for example ≥5% at a specified interval), medication adherence and ongoing participation in care management,” he explains. “Members who are not responding clinically may not be permitted to continue coverage, preventing plans from paying indefinitely for low-value treatment.” TPAs are increasingly tasked to offer strategies that help plan sponsors control costs, including negotiating aggressive rebates and outcomes-based contracts. “In their advisory role, TPAs are addressing a major issue: many patients remain on therapy long term, creating recurring costs,” says Roffe. “Managing the duration of therapy should include defining maintenance protocols, monitoring long-term effectiveness and reassessing eligibility periodically. The financial challenge is often not initiation of therapy but indefinite continuation.” Roffe emphasizes that a TPA can help clients measure the total cost of care, not simply the pharmacy spend, adding, “The smartest plans evaluate hospital admissions, diabetes costs, cardiovascular events, bariatric surgery avoidance and overall medical spend. A member generating $15,000 to $20,000 of annual GLP-1 cost may still be economically attractive if medical costs decline significantly.” TPAS AND MENTAL HEALTH

TPAs are deploying real cost-containment strategies, and across most medical spend those strategies work. But in behavioral health, Trevor Colhoun, CEO, TPN.health affirms that TPAs don't have the capability to find the efficient and effective process for a covered life, because the variable driving cost in high-acuity behavioral health isn't price — it's whether the member is matched to the right provider. 18

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High Cost Claims “That's the work we do at TPN.health,” he explains. “We go deep on the provider: understanding the specialty of each high-acuity provider, and how their quality of care matches their value. Credentialing and claims are part of that same picture, not a separate administrative exercise.” Colhoun says that at scale, that knowledge produces better rates and better outcomes at once: “….through high-acuity care navigation up front, clinically informed matching and personality scoring, and a scale of offerings that delivers value of service matched to what the member actually needs rather than what happens to be available." ARTIFICIAL INTELLIGENCE (AI) TO THE RESCUE

Trevor Colhoun

AI is rapidly becoming the difference-maker. Rather than waiting for a claim to hit six figures before intervening, AI-powered predictive models can flag high-risk members weeks or months earlier, scanning patterns in diagnosis codes, prior utilization and social determinants of health that a human reviewer might overlook. This represents a palpable shift from hindsight to foresight, allowing TPAs to loop in case managers, negotiate provider rates or guide members toward centers of excellence before costs spiral out of control. The result isn't just savings; it's better-coordinated care that leads to better outcomes. “Generative AI can fundamentally change how TPAs manage high-cost claims,” asserts Barbora Howell, co-founder and CEO of TrueClaim. “Instead of relying upon retrospective audits, AI can review every claim, surface anomalies and payment-integrity issues and give claims teams the context to intervene before payment. She points to an example at her organization, “We use AI to review 100% of claims and flag issues such as duplicate charges, medically unlikely edits, and upcoding for human validation. This allows experts to focus their attention where it matters most while saving the plan 7% of claims costs.” Equally important, Howell says the economics should be transparent, adding, “Employers should know exactly how every vendor and TPA is compensated. TrueClaim charges a transparent administrative fee, passes vendor costs through without markup and returns shared-savings incentives to the employer.” Barbora P. Howell

TPAS FACE LEGAL CHALLENGES

It’s not a bed of roses for the national TPAs as they face mounting legal challenges and scrutiny over highcost claims. These employer lawsuits are driven by issues spanning hidden fees, aggressive claim denials using automated tools, data-access restrictions, and heavy backlogs and high provider win rates in federal independent dispute resolution (IDR) processes under the No Surprises Act. Advisors at Withum maintain that rising medical claim denials are no longer a back-office nuisance; they represent a direct fiduciary risk under the Employee Retirement Income Security Act of 1974 (ERISA). They impart that every denial that delays care or reimbursement can expose plan sponsors to financial volatility, regulatory scrutiny and litigation, and as fiduciaries, employers must act prudently and solely in the interest of plan participants. Failure to monitor claim adjudication processes, especially those delegated 20

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High Cost Claims to third-party services providers, such as TPAs and PBMs, can result in breaches of ERISA duties and reputational harm. While many denials are clinically or contractually appropriate, Withum contends that the variability and frequency of denials across payers signal broader systemic issues that contribute to the rise in claim denials. FIDUCIARY AND LEGAL RISK

Under ERISA, plan sponsors must ensure claims are processed fairly and in compliance with plan terms. As claim denials continue to draw scrutiny, courts are increasingly clarifying how ERISA’s fiduciary standards apply to modern claims administration, especially when TPAs rely upon automation, algorithms or insufficient human review. Recent cases offer insight into how judges are evaluating these practices and the legal exposure that can arise when oversight is inadequate: •

Aramark v. Blue Cross and QCC Insurance Company

Most recently, a federal court case in Pennsylvania could show benefits managers and benefits advisors how the courts will handle employer plan suits based on the results of plan audits. A ruling lets Aramark — a food services and facilities management giant — move forward with some of the arguments it made in a suit against a health plan administrator. According to documents, Aramark based the suit on the results of an audit of some of its self-insured health plans. The list of defendants included Independence Blue Cross and QCC Insurance Company, an Independence Blue subsidiary that administers employer health plans. Aramark accused the defendants of breaching their fiduciary duty to the plan participants under ERISA and of engaging in transactions prohibited by ERISA. Aramark charges that the plans' TPA paid about 5,000 duplicate claims; hundreds of claims for telehealth services and other services excluded from coverage; and hundreds of claims with missing, invalid or unlisted claim codes. The company reportedly made plausible claims that the health plans' TPA now has "money wrongly held," and that QCC "had discretionary authority and responsibility in plan administration." •

K.D. v. Anthem Blue Cross and Blue Shield

The court found violations of the Mental Health Parity and Addiction Equity Act (MHPAEA) and ERISA when Anthem failed to provide adequate review for denied mental health claims. The ruling reinforced that plan sponsors must actively oversee appeals to avoid fiduciary breaches. 

Kisting-Leung et al. v. Cigna Corporation

Plaintiffs, consumers in California, filed a class action complaint alleging Cigna used an algorithm to deny claims in seconds without medical review. The court ruled that delegating medical necessity determinations to an algorithm violated plan terms and constituted an abuse of discretion, allowing fiduciary breach claims under ERISA to move forward. NOVEMBER 2026

High Cost Claims PLAN SPONSORS STRENGTHEN TPA OVERSIGHT

Denied claims aren't just paperwork headaches as they carry real fiduciary weight. When self-insured employers get this wrong, they risk regulatory scrutiny, lawsuits and damage to their reputation. ERISA puts plan sponsors on the hook for acting prudently and putting participants' interests first, and that duty doesn't disappear just because claims processing gets outsourced to a TPA. Relegating the day-today work isn't the same as handing off responsibility: Employers still need to stay engaged, tracking how denials are handled, auditing the claims process and confirming appeals meet the federal standard of a "full and fair review." Omitting this oversight isn't just precarious from a legal standpoint; it erodes the trust employees place in their benefits. Strong governance is what keeps a health plan sustainable over the long run. When employers invest in independent audits, push TPAs for transparent reporting, and lean on data to guide decisions, they can catch problems early, before small issues turn into systemic challenges. A positive outcome goes beyond staying compliant. This level of oversight builds employee trust and repositions health benefits as a strategic advantage rather than just a line-item expense. For self-insured employers, treating accountability and member advocacy as priorities serves a dual purpose: it protects the plan and signals a real commitment to employees, a key ingredient for maintaining and attracting top talent. Martin at Nova Health suggests, “An ethical TPA should be disclosing all of their fees within their proposals and administrative service agreements. Fees can get buried in many places such as subrogation, out-ofnetwork negotiations, PBM per-script commissions, as well as behind-the-scenes stop-loss overrides.”

ACTIVE COST MANAGEMENT DRIVES COST CONTAINMENT Go beyond routine processing, standard discounts and automated repricing. Determine what is appropriate. Engage the right decision-makers. Deliver the outcome.

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High Cost Claims CALLING FOR ACCOUNTABILITY

Litigation over fiduciary breaches and employer lawsuits against TPAs over hidden administrative charges, "shared savings" overpayment fees, and a lack of pricing transparency on expensive medical claims have prompted greater plan sponsor oversight and demands for accountability. Advisors at Withum offer some guidelines for employers: “Self-insured health plans can take proactive steps to strengthen oversight of their TPAs, who are often responsible for processing claims and managing provider networks. TPA oversight is important to reduce legal exposure, improve employee satisfaction, and fulfill their fiduciary duty to act in the best interest of plan members.” •

Establish clear performance benchmarks: Metrics such as denial rates, appeal success, and adjudication timelines should be reviewed regularly and incorporated into quarterly performance evaluations to identify trends and areas for improvement.

•

Demand transparency: Require detailed reporting on denials and appeals, including justifications and resolution outcomes.

•

Audit regularly: Independent audits can help uncover patterns of inappropriate denials and ensure ERISA compliance.

They recommend using data to drive governance and should consider adopting a proactive, data-driven approach to manage risk and improve outcomes. This includes analyzing claims data, utilization patterns, and denial rates to identify trends and systemic issues, as well as applying predictive modeling to forecast high-cost claims and adjust benefit design. As with all AI-driven initiatives, they recommend monitoring AI-driven adjudication for compliance and fairness. THE VALUE OF REPUTABLE TPAS

While many observers raise legitimate concerns about transparency, incentives and conflicts of interest, much of the strongest criticism of TPAs relies on allegations and selected examples from lawsuits rather than established industry-wide evidence and findings. The most productive approach for employers is not assuming all TPAs are good or bad, but demanding rigorous transparency, conflicts of interest, audit rights, claims-level data access and disclosure of all compensation streams. TPAs provide significant operational value, and employers should focus on these metrics rather than assuming misconduct. Dr. Roffe emphasizes, “A sophisticated TPA would likely agree that transparency and accountability are important, but I – along with many colleagues -- would challenge several conclusions made by critics. Some faultfinders claim that TPAs are the medical equivalent of PBMs and profit by increasing costs. In reality, most TPAs are primarily administrative entities, and it is the PBM that often directly influences drug pricing and pharmacy reimbursement.” Self-funded employers typically hire TPAs because they lack the infrastructure to adjudicate millions of claims, maintain provider networks, ensure regulatory compliance or manage customer service and appeals.

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High Cost Claims “TPA fees are usually a small fraction of total health plan spending,” Roffe points out. “Respected industry sources affirm that the overwhelming majority of costs come from medical claims, provider pricing, specialty drugs and utilization trends. It’s a fact that TPAs generally do not bear the medical claims risk in self-funded plans – it's the employers that do, and that is undisputed.” While some observers claim that network contracts are deliberately hidden, Roffe asserts, “Provider contracts often contain confidentiality clauses demanded by providers, not solely by insurers. Hospitals and physician systems frequently consider negotiated rates proprietary, and revealing all network contracts could undermine future negotiations and reduce network competitiveness. Employers often receive limited access to complete provider contracts, but this does not automatically indicate abusive pricing.” In response to criticisms that TPAs steer patients toward affiliated providers to increase profits, Dr. Roffe rebuts, “Many steering programs are designed around quality metrics, value-based care arrangements, narrow-network strategies and designated Centers of Excellence. There is growing consensus that integrated organizations can better coordinate care, improve outcomes and reduce unnecessary utilization.” Roffe states that out-of-network claims are notoriously difficult to manage, and TPAs require an experienced partner that can effectively combine PPO network agreements, attorney-led negotiations and detailed line-item bill reviews to support lower medical spend for their clients.

NOVEMBER 2026

High Cost Claims “This is an area where decades of experience can save employers substantial amounts that otherwise would have been paid at billed charges,” says Roffe. “The goal is to get providers to accept discounted rates on outof-network claims as a defensible payment in full for their services. The key is fast turnaround and an expert negotiating team that uses real people who are supported by AI and technologies.” TPA CLAIM REVIEW AND PLAN COMPLIANCE

Mike Lanza

TPAs are essentially caught between two competing responsibilities: maintaining provider networks and discounts while also properly administering the Plan document.

Michael Lanza, Senior Vice President, USBenefits Insurance Services, advises that provider contracts can restrict the ability to conduct claim-review audits, which can have a significant impact on the management of high-cost claims. “TPAs must have a comprehensive claim-review process that applies to both in-network and out-ofnetwork claims and ensures claims are covered under the terms of the Plan,” says Lanza. “Reviews should address medical necessity, experimental or investigational treatment, exclusions, limitations, billing accuracy, and other coverage provisions.” Payment of a claim that is not covered by the Plan creates compliance, fiduciary, financial, and contractual risks. “Ultimately, an effective claim-review program is not simply a cost-containment strategy,” cautions Lanza. “It is an essential component of proper Plan administration, adherence to the Plan document, fiduciary oversight and protection of Plan assets.”

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

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F E AT U R E

Behavioral Health’s

AI Balancing Act

While artificial intelligence could ease clinician workloads, questions about safety, trust and accountability persist. Written By Bruce Shutan

rtificial intelligence is revolutionizing the delivery of mental health and behavioral health treatment approaches in self-insured group health plans – at once showing great promise for helping lighten clinician loads but also causing deep concern over misuse of the technology. AI is being used both in and around treatment, while some of the most immediate opportunities are around the edges of treatment, observes Julie Marshall, Ph.D., chief of clinical psychology for ReviveHealth. “AI can help someone identify what they are experiencing, complete an initial assessment, navigate to the right type of care and get connected much faster,” she says. “It can also recognize patterns or concerning language that may indicate someone needs a higher level of support and bring a clinician into the process earlier.” On the provider side, she notes that AI can synthesize information, track symptoms over time, identify changes that might otherwise be missed and reduce administrative work that takes clinicians away from patients.

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AI Balancing Act Trevor Colhoun, CEO of TPN.health, sees a role for human-enabled AI at the beginning of therapeutic care. “People can feel safer talking to their phone first,” he says. “It’s not a replacement for true therapeutic work, but it can be a good start and opening to discovery.” A MORE RESPONSIVE ECOSYSTEM

The most significant opportunity for AI lies in transforming how people access mental health and behavioral health treatment, notes Dani Kimlinger, CEO of MINES and Associates, Inc., who believes AI can help build a more responsive behavioral health ecosystem. Trevor Colhoun

“For far too long, our industry has struggled with provider shortages, long wait times, fragmented navigation and delays in identifying individuals who need support,” she says. “AI has the potential to reduce that friction by supporting intake, care navigation, triage and curation of resources and support, provider matching and early identification of risk factors.” Her firm has been exploring AI-supported navigation tools such as Mellow, an AI-enabled intake and navigation assistant designed to help individuals move through the intake process more easily, understand available resources and connect to appropriate support pathways. David Zakariaie, CEO of Senseye, Inc., says his company is using AI to build an objective and real diagnostic and measurement platform for mental health. The hope is to enable the next generation of treatments, including precision psychiatry. “It’s certainly a very exciting time, and there are plenty of new tools that have the capability to help patients if and when they are used correctly, with appropriate safeguards in place,” he says.

Dani Kimlinger

Zakariaie hopes that AI and technology can help alleviate high demand for the short supply of mental health and behavioral health clinicians, given that there are more patients than professional capacity to see them. “Our focus is on putting some very powerful tools in the hands of the clinicians, but we have no intention of trying to replace them,” he adds. Many patients who are being referred to a specialist will most likely still need or desire some type of support while they’re waiting for their appointment over days or weeks. Zakariaie believes this will lead to a blended model of care. “AI or digital therapeutics could fill that gap and provide some form of relief and form of treatment in that in-between stage from when a patient is diagnosed to when they formally enter whatever treatment pathway is best for them,” he says. David Zakariaie

The way AI development at ReviveHealth is being guided is almost as an empathy engine, Marshall reports. The thinking is to use it as part of a larger care system that can better discern what someone needs in NOVEMBER 2026

AI Balancing Act the moment. Examples may include information, reassurance, a different level of explanation, clinical resources or human contact. “When used in this way,” she says, “AI can help anticipate stress, tailor the tone and timing of support and create a seamless path to human care when that is what’s needed. Sometimes, the best thing the technology can do is recognize this person needs a person.” However, she cautions that the experience of empathy is not the same as clinical judgment. “A chatbot can sound supportive while missing a serious safety concern or reinforcing something that should be challenged,” she adds. ADDRESSING CAVEATS

Mindful of the growing concern over AI’s creeping influence, Kimlinger says it’s important that clinical review, risk assessment, eligibility determinations and care decisions remain in the hands of trained professionals. The strategic question isn’t whether AI can make recommendations; it’s whether people can trust the systems making those recommendations, she opines, noting that trust is foundational to effective care. Caveats are less about technology and more about ethics, governance and trust, in her view. She points out how behavioral health involves deeply personal information and high-stakes decisions. “As AI becomes more integrated into care pathways, organizations must address privacy, informed consent, transparency, explainability, bias, accountability and patient safety,” she says. Responsible implementation requires clear governance structures, human oversight, auditability, accountability and transparency regarding how AI is being used and ongoing monitoring for unintended consequences, Kimlinger notes. She says key components of responsible AI deployment include human review of escalations, fairness monitoring, override capabilities, privacy protections and vendor due diligence. What’s worrisome to clinicians is circumstances that are beyond their control. Concern is mounting over how quickly individuals are using AI chatbots, particularly when they begin viewing general-purpose AI chatbots as substitutes for clinical care. Indeed, a growing number of Americans have turned to AI chatbots for health information. While nearly 30% have used the tools for advice on their physical health in the past year, one in six said they had used AI for their mental health, according to a recent Kaiser Family Foundation poll. “The reality is that millions of people are already using these tools for emotional support, mental health information and guidance,” Kimlinger reports. “That tells us something important, which is that there is significant unmet demand for accessible mental health support. I worry less about people using AI and more about people misunderstanding what AI is qualified to do.”

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AI Balancing Act IMPOSING SAFEGUARDS

Most general-purpose AI systems like ChatGPT weren’t designed to assess suicide risk, manage crises, diagnose mental health conditions or provide evidence-based treatment, she explains. While they may offer helpful information, she cautions that they shouldn’t be mistaken for a licensed clinician. “This is where governance becomes critical,” Kimlinger says, predicting that it will become one of the defining issues in behavioral healthcare over the next decade alongside transparency. “Organizations developing and deploying these tools should be transparent about limitations, build safeguards around crisis situations and clearly communicate when human intervention is needed. Technology can improve access, but we should be careful not to create a false sense of clinical expertise where none exists.” Zakariaie is concerned about dire consequences stemming from AI tools giving patients incorrect guidance, or in some cases, instructions on how to commit suicide. But he also notes that they can be used in situations where a full-on therapist isn’t needed, in between sessions or while someone is waiting to be enrolled in an evidence-based treatment program. The U.S. Food and Drug Administration has identified various AI risks, including inaccurate or biased responses and the potential to worsen symptoms, which is why Marshall says ongoing monitoring matters, not just testing a tool once and assuming it is safe.

Julie Marshall

Marshall worries that consumer adoption has moved much faster than the clinical standards and safeguards around AI. “People are going to use these tools, so the answer isn’t simply to discourage their use,” she notes. “We need safer systems and very clear pathways to human support when the situation calls for it.”

NOVEMBER 2026

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AI Balancing Act The American Medical Association has urged Congress to create guardrails for chatbot use in mental healthcare, while some states have moved to regulate this area. Examples include Illinois banning AI for therapeutic decision-making and California requiring chatbot developers to monitor conversations for signs of suicidal ideation, as well as other safeguards. A BLENDED CARE MODEL

The Centers for Medicare & Medicaid Services also began creating payment pathways for some technology-enabled behavioral health services, which Marshall says suggests that payers are becoming more open to these models. “My guess is that reimbursement will develop around blended care: AI used for screening, skill-building, monitoring, navigation or support between visits, with clinicians still responsible for diagnosis, treatment decisions and higher-risk care,” she says. A blended model can provide continuity between mental healthcare visits, according to Marshall. She says AI can extend the reach of clinicians and help people get the right level of support at the right time, without trying to replace the human relationship at the center of care. As AI becomes embedded in screening, triage, care navigation, treatment support and decision-making, Kimlinger says stakeholders will increasingly ask how a recommendation was generated, what it was informed by data, whether it was tested for bias and who is accountable if an error occurs.

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NOVEMBER 2026

AI Balancing Act Noting how on a given day, she is contacted by at least three to five AI behavioral health start-ups asking to collaborate, Kimlinger expects that reimbursement models will initially favor hybrid approaches that combine AI capabilities with licensed clinical oversight. Transparency will take on growing importance as advanced technology continues to blend with human support. “If AI is influencing diagnosis, treatment or therapeutic interactions, the standard should be much higher than it is for a general consumer tool,” Marshall suggests. “People should know when AI is involved, what it is designed to do, where its limits are, how their information is protected and when a human becomes involved.” OUTCOME AND VALUE

It comes down to outcomes and value, which Colhoun isn’t seeing within AI right now. “Think about why a provider is licensed and credentialed,” he says. “They’re accountable to an independent board that sets a code of ethics. If an AI agent breaches ethics or HIPAA, who’s responsible? Are we suing a robot? I think there is a path to be reimbursed with gateway processes into therapies, but for now I am not seeing a reimbursable path for actual therapeutic interventions.” The strongest predictor of outcomes is how the member connects with their therapist through care alliance, Colhoun notes. That means understanding culture, family of origin, demographics, shared experience and human confidence. “AI isn’t capable of that,” he explains. Over time, Marshall thinks payers may become less focused on whether care was delivered by a person or technology and more focused on whether the patient actually improved, received the right level of care and did so efficiently. “The future isn’t AI or a therapist; it’s people moving between self-directed tools, AI-enabled support and human care based on what they need,” she says. Looking ahead, Kimlinger believes the trajectory of behavioral health is not about artificial intelligence alone. “It is responsible intelligence, where technology expands access, empowers clinicians and helps more people receive the care they need when they need it,” she says.

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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EMERGING HEALTH PLAN COST REALITIES FOR NEWBORN & EARLY CHILDHOOD CARE

Written By Laura Carabello

hile the cost of childbirth and related expenses are intended to be the focus of this article, the recent mistrial of Lindsay Clancy, a Massachusetts nurse who killed her three children in 2023, had the nation riveted on the issues of postpartum psychosis. It is a topic that is further explored here, especially as it relates to an employer’s financial burdens and responsibilities for covering the cost of maternal care. If you’ve been out of the “baby scene” for any length of time, it may be surprising to hear some pundits proclaim that by the time a newborn leaves the hospital in 2026, many parents have already spent more on their first week of parenthood than on their first year of rent. Observers often quip that the average family will spend more keeping a baby alive in year one than keeping a car on the road for five. Just how big are these expenses? According to the KFF Health Systems Tracker, on average, the health costs associated with pregnancy, childbirth and postpartum care amount to $20,416, including $2,743 in out-of-pocket expenses, for women enrolled in employer plans.

•

Childbirth and postpartum health spending among employer health plan enrollees varies by the type of delivery

•

Costs for pregnancies resulting in a vaginal delivery average $15,712 ($2,563 of which is paid outof-pocket), while those resulting in cesarean section (C-section) average $28,998 ($3,071 of which is paid out-of-pocket).

•

Additionally, the medical costs associated with toddlers in their first two years of life average $16,575, with $1,511 paid out-of-pocket. THE SELF-INSURER

Jason Hines, CEO and co-founder at Gigasheet, a price intelligence platform, reports on a recent partnership with the Health Care Cost Institute to analyze negotiated childbirth prices using Transparency in Coverage data.

Jason Hines

Hines informs, “Our findings show substantial variation in childbirth prices -- as much as a twofold difference even within the same hospital. Across a sampling of 116 metro areas, the median price at the most expensive hospital was 2.6 times the price at the least expensive hospital. Data points like this can help employers and benefits advisors better understand what plans are paying, and we're finding it's useful evidence for the discussion around maternal and newborn healthcare costs.”

The 2026 Sun Life High-Cost Claims Report identifies newborn and infant care as a leading cause of catastrophic, million-dollar-plus medical claims, primarily driven by long-term NICU stays. While top cases can exceed $11 million, the average cost for these claims is approximately $629,882.

PROS AND CONS OF PERINATAL COVERAGE

Whether employer benefits packages should cover premature births and neonatal care is a complex policy debate balancing worker support, healthcare costs and corporate financial responsibility. Proponents argue coverage reduces long-term costs and boosts retention, while critics point to rising group insurance premiums for all workers. But the arguments for coverage are swaying employers in this direction. David Ostrowsky, manager, Corporate Communications, The Phia Group LLC, confirms, “It is absolutely worthwhile for self-funded employers to invest in family and childcare benefits. For many employees, their most daunting medical expenses will relate to maternity care and newborn services – particularly if there is an extended stay involved, such as in the NICU.”

David Ostrowsky

He points out that subsequent bills can easily amount to tens of thousands of dollars, if not hundreds of thousands. NOVEMBER 2026

“Having that peace of mind that your out-of-pocket expenses will be manageable is nothing short of a game changer and a prime reason why many people will want to stay at a company that offers such benefits and remain highly engaged,” says Ostrowsky. “In terms of recruiting, in this day and age of soaring healthcare deductibles and copays/co-insurance, the ability to offer first-rate family and childcare benefits is a perfect way to stand out from the competition, as so many companies do not prioritize their employees’ collective welfare in such a manner.” FINANCIAL PROTECTION

This is undoubtedly the leading reason for offering coverage, as it can mitigate or prevent families from facing catastrophic debt related to a medical crisis during pregnancy or delivery. These events typically involve severe conditions like heavy bleeding, severe high blood pressure or infections where timely – often costly intervention -- saves lives. Many emergency situations require immediate hospital care, emergency surgery or blood pressure monitoring. Researchers report in JAMA that financial hardship is highly prevalent among peripartum women, defined as pregnancy and the 12 months after delivery. Surprisingly, women with private insurance were more likely to experience unaffordable healthcare. The Policy Center for Maternal Mental Health attests that the most frequently reported issue was the financial burden associated with accessing maternal mental healthcare. Many respondents to its survey described having insurance coverage on paper but still being unable to afford treatment. The reasons cited included: •

High deductibles averaging around $3,500

•

Therapy sessions that cost $200–$300 per week before their deductible is met

•

Large co-pays for ongoing mental health treatment

•

Out-of-network denials and telehealth coverage limitations

Several respondents described what many referred to as the “gap” experienced by middle-income families: earning too much to qualify for Medicaid, but not enough to comfortably afford private insurance costs and high out-of-pocket medical expenses. Some families reported paying as much as $12,000 out-of-pocket for pregnancy and delivery-related care alone. These financial realities often forced families to delay treatment, reduce therapy frequency, or forgo care entirely during pregnancy and postpartum recovery. PRODUCTIVITY

Peripartum women who receive robust support from their employers generally experience less stress and distraction, report lower anxiety and demonstrate higher job retention and overall productivity. That’s the consensus of industry observers who advocate that supported employees often transition more smoothly and maintain better long-term engagement with their roles. Everyone acknowledges that becoming a mother is life-changing, but for working women, this transition often brings emotional strain rather than celebration. At the intersection of new childcare responsibilities, the anxiety of managing hormonal shifts and changing professional expectations, many mothers experience increased stress, depression or anxiety. If these conditions remain unsupported, there may be profound consequences for both employee and employer. Time magazine reports an average of 1 out of 4 women exits the workforce during the first year of motherhood. 38

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And here’s a term that many may find unfamiliar: maternal postpartum work resumption stress (PWRS). Analysts insist that it remains under-studied, but one prospective study examined changes in, and determinants of, maternal PWRS during the return-to-work transition. Results from a self-reported questionnaire that was collected from two weeks before re-entry to six months afterward showed the highest levels of PWRS at the start of the transition, followed by a linear decline over the subsequent six months. Analyses showed that while mothers tended to express fewer child-related concerns and reported increasing enrichment from returning to work over time, they continued to struggle with work–life balance. PWRS was associated with mothers’ psychological capital, recovery from giving birth, length of maternity leave, working hours, infant negative affectivity and workplace support. GROWING DEMAND FOR PAID PARENTAL LEAVE

Paid maternity leave is job-protected time off for employees to recover from childbirth and bond with a new child while receiving partial or full wage replacement. As of 2026 in the US, there's no federal paid maternity leave law, although the National Conference of State Legislators confirms that 14 states and Washington, DC have enacted laws. The protections that do exist come from a combination of state programs, employer policies and, in some cases, short-term disability insurance. The US Department of Labor enforces the Family and Medical Leave Act (FMLA), the federal baseline for maternity leave. It provides up to 12 weeks of unpaid, job-protected leave for eligible employees at covered employers (those with 50 or more employees within a 75-mile radius). Employees must have worked at least 12 months and 1,250 hours to qualify. The key word here is unpaid. FMLA guarantees the job will be there when the employee returns, but it doesn't require the employer to pay the individual during leave. That's the critical difference between FMLA and paid leave, and it's why state paid family leave programs exist. But the sentiment among most women is that the amount of paid leave offered by most employers is inadequate. In its Fourth Annual State of Maternal Health in America report, The Harris Poll found that 64% of women considered paid leave insufficient and that percentage rose to 71% among women diagnosed with a mental health condition during pregnancy, postpartum or while trying to conceive.

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Indicative of this trend, Amazon is now facing a proposed nationwide class-action lawsuit alleging that it systematically denied pregnant workers basic workplace accommodations and punished some employees for pregnancy-related absences. Filed recently, the lawsuit was brought by four former Amazon warehouse employees. The complaint alleges that Amazon denied workers accommodations such as chairs, bathroom and water breaks, and time off for prenatal appointments. It also alleges that the company required medical documentation "beyond self-attestation" when seeking accommodations and fired some workers after they exceeded limits on unpaid time off. STATE PROGRAMS

Most state programs are structured as paid family leave rather than paid maternity leave specifically. Paid family leave by state typically covers: •

Bonding with a new child (birth, adoption, or foster placement)

•

Caring for a family member with a serious health condition

•

Military caregiver leave

•

In some states, safe leave for domestic violence situations

This means the same program that provides paid pregnancy leave also covers fathers, adoptive parents, and other caregiving situations. In most states with a paid family leave program, fathers can take paid parental leave. It’s important to note that multi-state employers must manage different contribution rates, eligibility rules, and benefit structures for each state where employees work, since the employee's work state determines which laws apply.

There is so much to give thanks for, especially good health. Our health benefits ecosystem brings together: • Decades of experience with core administration • The right point solutions and strategy to connect them

So we can: • Elevate the member experience • Control costs in ways traditional TPAs cannot

We’re grateful for our self-funded community who share our passion for evolving healthcare.

hpiTPA.com

NOVEMBER 2026

Source: July 2026 Rippling

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MORE THAN A BENEFIT PERK

Employers are learning that paid leave is more than a benefit sweetener: Parento states that it is now the third most requested workplace benefit, perk or incentive for those 41 and younger. While there is no federal mandate for paid parental leave, private US employers increasingly adopt or expand competitive policies to navigate shifting state requirements and attract talent. Source: Parento With the limitations of Paid Family Leave (PFL) and ShortTerm Disability (STD) plans, paid parental leave remains a key focus for employers as a strategic advantage to attract and retain top talent. UNUM reports a staggering 33% of employees request additional maternity leave, while 47% are looking for expanded family leave options, reflecting the changing priorities in today's society. Nava Benefits maintains that the data on paid parental leave prevalence tells two different stories depending on who you ask: The International Foundation of Employee Benefit Plans (IFEBP) found that 62% of organizations offer paid parental leave, while the US Bureau of Labor Statistics National Compensation Survey — which measures what workers can actually access, not just what employers say they offer — found that only 27% of private-industry workers have access to paid family leave through their employer. But analysts at Gallagher state that over the past five years, employer-provided paid parental leave has expanded significantly, and its survey shows that more than 45% of U.S. employers currently offer parental leave. This growth reflects a broader societal emphasis on supporting families and improving employee well-being during major life transitions. Gallagher advises that employers should begin with a comprehensive analysis of their current programs:  Assess employee priorities: Understand how employees value leave benefits relative to other

offerings such as healthcare, retirement plans and compensation. This insight helps determine which programs have the greatest impact on attraction and retention.

 Benchmark against the market: Compare parental leave and other time-off programs with industry

peers. Key factors include eligibility requirements, duration, pay levels, job protection and usage flexibility. This analysis highlights opportunities to refine or reposition offerings.

 Evaluate utilization and impact: Examine how leave programs are used across departments

and roles. Identify trends in frequency, duration and timing, as well as the effects on staffing, productivity and costs. Detailed data provides a more accurate picture of program performance. NOVEMBER 2026

NICU-SPECIFIC LEAVE

Surprisingly, one in ten American families begins parenthood in the Neonatal Intensive Care Unit. When a newborn requires specialized medical attention, the NICU -- a unit in the hospital designed to support babies who need close monitoring, advanced treatments or life-saving interventions -- becomes a vital part of their care. Researchers at the National Center for Health Statistics (NCHS), a branch of the Centers for Disease Control and Prevention (CDC), report that 9.8% of all infants in the US are born preterm. The data is pulled directly from the National Vital Statistics System (NVSS), which tracks every birth certificate issued across the country. But other investigators argue that this data may underestimate the true prevalence: a study published in Nature showed that 38% of infants who were truly admitted to a NICU did not have a NICU admission on their birth certificates and missed NICU admission occurred across all gestational ages. Birth certificates missed more than half of NICU admissions among term infants (37+ weeks), including among those with conditions considered to be severe. Percentage of infants admitted to a NICU: United States, 2016–2023 SOURCE: National Center for Health Statistics, National Vital Statistics System, natality data file. Preterm birth can have a profound impact on families, contributing to emotional challenges, sudden changes in family dynamics, and increased caregiving and financial demands. During this challenging time, many NICU parents are caught between the competing demands of their jobs and the health and well-being of themselves and their new babies. But the cost of NICU care can be overwhelming: Care Route, which provides services that guide patients to the right level of care, estimates billed charges for NICU care are large -- roughly $3,000 to $5,000 per day at the special-care level, $5,000 to $8,000 per day in a full NICU, and more than $10,000 per day at the highest level. Long stays can reach six or even seven figures. For families covered by employer-sponsored health insurance in 2026, the employer's health plan usually covers the vast majority of NICU costs—often absorbing 90% to 95% or more of the total bill. Because NICU stays are high-cost medical events, billed charges regularly range from $3,000 to $10,000+ per day, resulting in total bills that easily scale from $70,000 to multiple six figures. 44

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What many employees may do, even before they come home from the hospital, is to formally add/enroll their baby in the employer’s health plan within the special enrollment window – typically 30 days on employer plans. When they enroll in time, coverage is retroactive to the date of birth, so the whole NICU stay is covered from day one. Advocacy organizations such as A Better Balance maintain that working parents of preterm infants need “…dedicated NICU leave so they can spend critical time with their babies and heal during the postpartum period. With NICU leave, families will have more flexibility and opportunity to bond with their preterm infants, cope with—and recover from—childbirth, understand their infants’ unique developmental needs, and learn how to safely manage ongoing health conditions.” They argue that access to workplace leave when a parent has an infant in the NICU not only benefits the infant’s health and well-being but also helps working parents take care of themselves and adjust to their new normal. COST OF IGNORING MATERNAL HEALTH IN THE WORKPLACE

There are some solid reasons why many new mothers return to work before they feel physically, mentally, or emotionally ready: limited leave policies, lack of workplace accommodations and a general misunderstanding of postpartum recovery. Postpartum Care USA contends that as a result, postpartum employees are often disengaged, exhausted, and struggling—impacting both their performance and overall company morale. The organization warns that if companies fail to provide support, they risk losing top talent—and the cost of replacing a valuable employee is 1.5 to 2 times their annual salary. The advocacy organization says their data speaks for itself:  95% of postpartum moms are disengaged employees for up to 3 years postpartum.  77% of postpartum dads experience a decline in engagement for up to 1.5 years postpartum.  Depression and anxiety (both common postpartum conditions) are among the top 5 reasons for

absenteeism and presenteeism in the workplace.

 46% of highly skilled women leave the workforce after becoming mothers.

Perinatal Mood and Anxiety Disorders (PMAD)

Source: Mathematica

NOVEMBER 2026

The Western University of Health Sciences–Oregon confirms that untreated PMADs currently cost U.S. employers $14 billion annually, or $31,800 per affected employee. Employers often focus on the cost of pregnancy and NICU claims but overlook one of the most significant workforce risks: postpartum mental health, advises Dani Kimlinger, PhD, MHA, SPHR, SHRM-SCP, CEO, Mines and Associates. “The most expensive newborn-related issue may not be the delivery itself -- it may be the untreated postpartum depression, anxiety, trauma, or caregiver stress that follows,” she explains. “We would never expect an employee recovering from a major medical event to simply ‘push through,’ yet many new parents experiencing significant mental health challenges are expected to do exactly that.” She says the real question is not whether employers are paying for postpartum conditions, adding, “They already are through lost productivity, absenteeism, disability, turnover and increased healthcare utilization. The Dani Kimlinger question is whether those costs are addressed proactively or reactively. Supporting families requires more than paying claims. It requires integrating behavioral health, parental support, childcare resources, leave programs, and care navigation into a coordinated system that helps employees thrive at work and at home.” David Zakariaie, CEO, Senseye states that maternal mental health does not lack attention but,” It lacks attention that arrives before a catastrophe, and attention that looks past a single diagnosis.”Zakariaie asserts that this past summer, the subject has been inescapable.

David Zakariaie

“The trial of Lindsay Clancy, the Massachusetts nurse who killed her three children in 2023, ended in a mistrial on September 4 after a deadlocked jury spent six days on whether postpartum psychosis had left her unable to be held responsible. Testimony described a woman who sought help repeatedly — psychiatrists, therapists, an outpatient program, inpatient care, several medications — while being treated for insomnia, anxiety and depression. A leading postpartum psychosis researcher told the court this was a classic case of the illness going undiagnosed and untreated.”

He says psychosis is not post-traumatic stress and clinically, the two share almost nothing. “What they share is a system that was built to find something else,” he continues. “Postpartum care in the United States is organized around depression, and conditions that do not present as depression tend to be found late or not at all.” Zakariaie explains that post-traumatic stress arising from the birth itself is one of them, noting that between 3-6% of new mothers develop PTSD from childbirth, rising to 16-19% among higher-risk groups — women who deliver prematurely, suffer a stillbirth, or face a dangerous complication like preeclampsia. Against 3.6 million US births a year, that is well over a hundred thousand women annually. “Routine care is not designed to find them,” he says. “The standard postpartum questionnaire asks about depression and anxiety and contains no questions about trauma. Trauma instruments exist in professional guidance, but sit downstream, reached only once a depression screen has registered a concern.” 46

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What concerns him is that gate is almost never opened. In 2023, health plans documented a postpartum depression screen for 8.7 percent of Medicaid enrollees and 4.4 percent of women with commercial coverage. Among those who screened positive, roughly a third received no documented follow-up. “The sequencing problem is real, but it is secondary: for the overwhelming majority of new mothers, the screen that would trigger a trauma question never happens,” he decries. “The reason the missed label matters is that the two conditions lead to different places. Therapy that works by processing the birth has been tested in postpartum women, with early evidence that it helps. The newest drug approved for postpartum depression, zuranolone, carries no approval for PTSD. A woman identified as depressed enters one pathway; a woman with untreated birth trauma needs the other. The label is the switch.” He warns that the cost of leaving that trauma untreated is measurable. “Birth-related PTSD is associated with shorter breastfeeding duration and with difficulty forming a bond with the infant, who can become a reminder of the birth rather than a relief from it,” he notes. “The bonding evidence is largely cross-sectional and cannot establish which comes first. But the direction of the clinical problem is not in doubt: a diagnosis that points a woman away from trauma treatment delays the only intervention shown to interrupt any of it. Attention, this summer, has not been the scarce resource. Precision has.” Screening for postpartum mental health conditions is the easy part -- giving mothers and families valuable access to care is not. Trevor Colhoun, CEO, TPN.health, cautions, “A positive screen that doesn't lead to care isn't helpful. Our approach at TPN.health is to understand these families on a human level first by providing them with a Care Navigator (always a licensed behavioral health provider) who can create a path to recovery and guide the member through it. That's how a screening result turns into an actual recovery. And it's the difference between an employer absorbing lost productivity, absenteeism, and turnover, or getting ahead of it." INADEQUATE CHILD CARE

Insufficient childcare for children below kindergarten age is another worrisome issue. A new study by Ready Nation measured the economic toll of the nation’s childcare crisis: the failure to significantly strengthen the country’s fragile childcare infrastructure has led to escalating economic damage to employers, workers and taxpayers, now costing $172 billion in lost earnings, productivity and revenue every year.

NOVEMBER 2026

This new national poll of 801 working parents of young children showed more than 60% reported that childcare struggles led them to leave work early, be late for work, miss full days of work or become distracted at work. About half missed part of a work shift. Productivity problems cause employers to lose $38 billion annually due to childcare challenges faced by their workforce, and taxpayers, in turn, lose $37 billion each year in lower federal and state tax revenue. A REALITY CHECK

Despite the groundswell of support from various organizations, the subject of parental leave is meeting some real-world pushback. Business Insider reported that recently, Zoom and Deloitte cut their paid parental leave benefits, with both companies stating that they are bringing their offerings in line with market norms.  Zoom reduced birthing parent leave from 22 to 24 weeks down to 18 and cut non-birthing parent leave from 16 weeks to 10.  Deloitte's cuts are narrower in scope, targeting parental leave, PTO, pension plans, and IVF funding for employees in support roles like administrative services, IT, and finance. Mercer responded to this news, saying it runs counter to the rapid expansion that Mercer has seen in paid parental leave benefits over the last decade. According to the most recent Mercer’s Absence and Disability Survey, the percent of employers offering paid parental leave for child bonding jumped from about 25% in 2015 to nearly 75% in 2024. Mercer analysts say the ROI for paid parental leave may be questionable since it can be hard to prove, making generous policies vulnerable to scrutiny. Mercer shares this perspective: “It’s easy to pick on paid parental leave when budgets tighten because the ROI isn’t always captured in neat financial metrics. That doesn’t mean employers should immediately trim these programs. Instead, take a careful approach: measure where you can, prioritize programs that clearly drive business goals, and weigh the real — and sometimes hidden — costs of eroding a benefit that employees increasingly view as essential.”Furthermore, while the cutback announcements generated headlines, the 2026 employee benefit trends study by MetLife showed that of 2,550 full-time U.S. employees, vacation, disability, and paid parental leave were the most prized benefits.

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Source: 2026 Cocoon. A TriNet Company WHAT EMPLOYERS CAN DO

but also contributes to a happier and more productive workforce overall.

Benefit Bump advises that there are many ways that employers can support new mothers during the postpartum period. By offering flexible work schedules, providing mental health resources, providing lactation support, creating a supportive work environment, offering maternity and parental leave and communicating benefits clearly, employers can help new mothers thrive both in and out of the workplace. This not only benefits the mother

Offer Flexible Work Schedules: This could include flexible start and end times, the option to work from home, or reduced hours for a certain period. Provide Mental Health Resources: Ensure access to mental health resources, such as an Employee Assistance Program (EAP) or a mental health hotline. Create a Supportive Work Environment: Include things like providing a private room for breastfeeding or pumping, allowing for breaks to take care of their baby, or providing resources for childcare. Lactation Support: Lactation Consultants play an important role in driving positive outcomes and supporting families who choose to breastfeed. They can educate, provide information, and support new parents on their breastfeeding goals. Offer Maternity Leave and Parental Leave to Non-birth Parents if Possible: Offering parental leave to nonbirth parents gives fathers a chance to bond with the baby as well, leading to better health outcomes for both mother and baby.

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Here are some practical – no cost -- recommendations for plan sponsors from the Mitch Daniels School of Business at Purdue: 1. Help women navigate the HR policies in your organization. There is nothing more stressful than sorting

through pages of HR policy when you are feeling sick and exhausted during pregnancy, wondering if you’ll qualify for paid leave or not. As a supervisor or leader, being well-versed and ready to help working mothers versus taking a more reactive approach and waiting for questions to arise is crucial. It is also advantageous to start a network of knowledge surrounding leave policies, connecting expectant moms to others who have already gone through the system.

2. Try to be flexible. Remote and hybrid work arrangements can be great options for moms as they

transition back to work and are not only navigating childcare, but other demands like breastfeeding and pumping breast milk. I’d also encourage organizations to think about how flexible they can really be. For instance, can babies — or even young kids — come to work? While this may not be advantageous day-to-day, it may help moms (and dads!) when care falls through. It can also signal to employees that they can be their whole selves at work and not hide that they are parents.

3. Celebrate moms returning to work. Do not make them feel guilty for taking time away or ask how their

“vacation” was from work. Celebrate that they’re back and you’ve missed their contributions. Ask for those baby pictures and acknowledge that they have had a transformative experience. Make them feel whole and give them grace as they adjust.

From a financial perspective, Dr. Bruce Roffe, president and CEO, H.H.C. Group advises, “The biggest savings generally comes before the baby is born, not after. Preventing a single very premature birth can save tens or even hundreds of thousands of dollars, whereas negotiating a slightly lower NICU rate often has a much smaller impact.” Putting himself in the shoes of a health plan sponsor or CFO and based upon his 31+ years of experience in cost containment achieved by cost management initiatives, Roffe would focus resources in this order:

Bruce Roffe



Reduce prematurity.



Maternal case management for high-risk pregnancies.



NICU admission appropriateness review.



NICU length-of-stay management.



Provider and hospital performance measurement.



Readmission prevention.



Value-based maternity contracts.

WHAT ABOUT DADS?

When a partner is also able to take leave, many experts insist that the physical and mental health benefits are evident for the individual, as well as the main caregiver and child. Several studies suggest that paternity leave has important impacts on the quality of child-father relationships as well as on the relationship of the parents. NOVEMBER 2026

According to a McKinsey study on parental leave, men who took paternity leave viewed it positively, with 100% reporting they were glad they took the time off and would do so again, and 90% reporting an improvement in their relationship with their partner. Other studies show:

•

The burden of household chores and childcare is more evenly distributed, and parental bonds are strengthened when both caregivers take leave.

•

Even short periods of paternity leave were found to be associated with a decreased risk of divorce for several years.

•

Paternity leave can also help reduce the gender wage gap, with one study that looked at over 9,000 families finding that for each month the father was on parental leave, the mothers’ incomes rose by about seven percent.

•

Fathers’ parental leave has also been shown to impact future family decisions about childcare and household responsibilities, with fathers’ leave-taking associated with a more equitable distribution between partners.

Ironically, one of the biggest employer benefits of paternity leave is what it does for retaining female talent in the workforce. When parental leave is a shared benefit, women are less likely to be pushed out of the workforce or passed over for advancement due to assumed caregiving burdens. 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

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Sources

https://www.healthsystemtracker.org/brief/health-costs-associated-with-pregnancy-childbirth-and-postpartum-care/ https://policycentermmh.org/the-cost-burden-of-maternity-care/ Large Employers - Scoop Health https://pmc.ncbi.nlm.nih.gov/articles/PMC11269272/ https://pmc.ncbi.nlm.nih.gov/articles/PMC8556621/ What Families and Providers Told Us About Insurance Barriers to Maternal Mental Health Care - Policy Center for Maternal Mental Health Returning to work after maternity leave: a longitudinal study exploring changes in postpartum work resumption stress and its determinants Self-Efficacy and Productivity in Working Mothers https://business.purdue.edu/daniels-insights/posts/2025/supporting-postpartum-mothers-upon-their-return-to-the-workplace. php https://time.com/7293659/transition-month-new-moms-work-essay/ https://behavioralhealthnews.org/supporting-maternal-mental-health-in-the-workplace-policies-practices-and-culture-change/ Most U.S. workers value time off, flexibility, and paid leave benefits What data does the BLS publish on family leave? : U.S. Bureau of Labor Statistics Paid Maternity Leave by State: 2026 Employer Compliance Guide https://www.dol.gov/agencies/whd/fmlaFrom Parental to Bereavement: New Data on Paid Leave Trends in the U.S. Children and Families: State Policies on Paid Family Leave Why Companies Need to Invest in Maternal Healthcare for Employees | Postpartum Care USA https://www.linkedin.com/posts/lynnmcfarland_untreatedperinatal-mood-and-anxiety-disorders-activity7404717474077818880-attz/ Deloitte and Zoom cut parental leave and other benefits - Fast Company 2026 MetLife Employee Benefit Trends Study (EBTS) https://www.instituteforchildsuccess.org/cost-child-care-crisis/ https://view.ceros.com/sun-life/high-cost-claims-and-injectable-drugs-report/p/1 https://www.mercer.com/en-us/insights/us-health-news/is-paid-parental-leave-on-the-chopping-block/ https://www.cdc.gov/ nchs/products/databriefs/db525.htm https://www.abetterbalance.org/resources/issue-spotlight-nicu-leave-is-a-common-sense-policy-that-supports-workingfamilies-and-improves-the-health-of-nicu-parents-and-babies/ https://www.careroute.ai/blog/nicu-cost https://www.nature.com/articles/s41372-026-02619-8 https://www.healthcare.gov/glossary/out-of-pocket-maximum-limit/ HHS Revises Out-of-Pocket Maximum Limits for 2026 https://www.cocoon.com/tools/paid-leave-benchmarks Paid parental leave is more than just a workplace perk | Employee Benefit News Fathers' Paternity Leave-Taking and Children's Perceptions of Father-Child Relationships in the United States - PubMed https://www.mckinsey.com/capabilities/people-and-organization/our-insights/a-fresh-look-at-paternity-leave-why-the-benefitsextend-beyond-the-personal https://docs.iza.org/dp11873.pdf https://www.benefitnews.com/tag/financial-wellness https://www.ifau.se/globalassets/pdf/se/2010/wp10-4-The-effect-of-own-and-spousal-parental-leave-on-earnings.pdf https://www.benefitnews.com/opinion/its-time-to-re-evaluate-paid-parental-leave Paid parental leave is more than just a workplace perk | Employee Benefit News https://infogram.com/median-parental-leave-by-company-size-2025-1h1749wrvj05q2z https://www.benefitnews.com/opinion/paid-parental-leave-is-more-than-just-a-workplace-perk Employer maternity leave falls short, says 64% of women Amazon sued over alleged pregnancy accommodation failures

NOVEMBER 2026

THINKING OUTSIDE THE OPEN ENROLLMENT BOX The key to a superior open enrollment, more informed decisions and better outcomes lies in disrupting this annual benefits rite

Written By Bruce Shutan

or self-insured employers, industry observers say investing in the best point solutions on the market will never pay off without a well-run open enrollment and education campaign that explains health benefit plans with clarity and brevity through multiple channels. As part of that annual rite, they must be willing to ditch longstanding practices for novel approaches that will help employee populations better absorb the information being shared. Only then can they expect a substantial return on their investment in the form of wiser benefit selections, higher satisfaction and better outcomes. One way to ensure that the OE experience turns out to be efficient and meaningful for group health plan members is to think about it in terms of addition by subtraction. That means avoiding piles of paperbased communications, lengthy cookie-cutter presentations, clogged email inboxes, long signup periods, a Monday start and 1/1 effective date, says Eric Silverman, founder and owner of Voluntary Disruption, a division of the Silverman Benefits Group. Instead, he suggests more nimble strategies that are better suited to the needs and preferences of today’s workforce. While many employers announce open enrollment with an email blast, Silverman believes the little red dot showing people that they have a text message waiting to be answered on their iPhone or Android mobile device will capture their attention much quicker.

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That’s not to say employers shouldn’t send an email, which can end up in a spam folder or pile up with unanswered correspondence. His recommendation is to pursue an omni-channel approach when it comes to communications.

Eric Silverman

Silverman laments that employees and their families are being asked to make key decisions about their benefits in a vacuum over the course of several weeks with very little to no support. “I’m a big believer in communication using the remote control of everybody’s daily life in the year 2026 and moving fast into 2027, which is their smartphone or mobile device,” he says.

Justin White, a producer and regional managing director for employee benefits at Oakbridge Insurance, believes there’s real power in harnessing how comfortable people are with texting. His firm offers its employer clients access to an employer-sponsored virtual telehealth service called TextCare wherein users have direct access to providers without downloading an app. VIDEO SLAYS THE EMPLOYEE HANDBOOK

Weighing the benefits of in-person vs. virtual meetings, Silverman suggests more of a hybrid approach that favors the latter at a time when nearly everyone has a smartphone, tablet or laptop that allows them to join various video-conferencing platforms. They’re also easier to schedule, can be recorded for later viewing with family members and help increase attendance. “They don’t have to be on video,” he hastens to add. “They can dial right in on the phone and listen on their own timeframe.” The way materials are communicated is one of the most important Justin White considerations. Many of the benefit packets employers print that run dozens of pages often end up left behind on conference tables, tossed into trash cans or recycle bins at in-person meetings, Silverman explains, noting how that investment wastes dollars that can be spent more wisely and help save trees. White recalls how he reacted to receiving a 12-inch-thick packet of information with summary plan descriptions and other documents in his first job after graduating college. “It was way too much information for me to comprehend,” he says. “Knowing I had a limited time to enroll and nobody to explain it to me, I took the most expensive of everything because I figured that meant I had the best coverage.” That anxious experience served as a teachable moment years later when White became an employee benefits consultant and decided to promote a concise benefit guide for every one of his employer clients at open enrollment. One example of more effective communication that reflects current practices is to record bite-sized video clips that are hyper-focused on each benefit being offered with their own links. That way, Silverman says, someone can click only on links that they find relevant. “Why should we make an employee scroll and suffer through a video that’s an hour long because they want to hear the minute-and-a-half clip on how pet insurance works?” he asks. NOVEMBER 2026

90 Degree Benefits is now looking into producing short video presentations that HR teams can use when they’re onboarding new hires because some field reps for many groups wear multiple hats and benefits are not their forte, reports Delene Lee, the third-party administrator’s manager of account management. SHORTER IS SWEETER

A shorter OE will turn out to be sweeter for employers and employees alike, according to Silverman. Allowing employees up to an entire month for their benefit selections is far too long, he warns. He has noticed a familiar pattern Delene Lee emerge in each enrollment his firm handles: type-A personalities who decide what to do on Day One, little to no movement over the remaining enrollment window and a flood of procrastinators making decisions on the very last day. “Think of the time and aggravation you could save by confining open enrollment to just one week,” Silverman suggests. The start date is also critical. Noting how Mondays tend to be chaotic for everyone, he suggests starting on Tuesday, Wednesday or Thursday, running it to the following week and providing one full weekend in the middle so employees can sit down with family members and decide together on what coverage they want. Silverman recommends being more thoughtful and daring about the actual timetable. Estimating that as many as 70% of all benefit selections take effect on January 1, he says it’s better to avoid the Q4 madness altogether by picking an off-peak target date. “We brainwashed employers into thinking that everything has to be clean,” he opines. “It’s absolutely untrue.” Far too many employers believe their benefits need to take effect on January 1 because most of the fully insured carriers have calendar-year deductibles, observes Lee, whose clientele has plans that renew every month of the year. There are also 30-day windows prior to and following the effective date for the open enrollments she handles to correct any errors or oversights or respond to eligibility changes. Allowing enough time to plan for open enrollment cannot be overstated, according to Lee, who says staffers and employees alike should be notified through email, posters, or flyers typically two months out. While a truncated timetable may force employers to be more efficient about the OE process, it may have an adverse effect on the results. When traveling to multiple locations for in-person open-enrollment meetings is involved, Lee says there’s typically going to be a longer window for employees to select their benefits. But allowing enough time can produce a better outcome. “The experience works better for the employees if they have somebody that’s actually there talking to them because they’re more likely to ask questions and get a better feel for multiple plan options,” she says, explaining that sometimes a TPA rep will do a joint presentation with the employer’s broker for greater impact. RAISING RETENTION

Putting more effort into open enrollment not only can increase employee engagement and improve coverage choices, it also can help raise retention. But benefit leaders also note the importance of better onboarding of new hires to combat high turnover. 56

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Lee cites as an example a large group she works with that every year devotes tremendous effort into distributing posters and flyers, conducting webinars with managers and training all the HR field reps. “When we go out and talk to all the employees at their brand-new stores, enrollment skyrockets,” she reports, noting how meetings featuring proper communication can help move the needle on enrollment. “They also have a lot of turnover. So, as employees are being hired, that same effort is not going into the new hires because they don’t have that level of communication, and enrollment starts to drop off again.” She says the key isn’t just communicating at open enrollment – it’s also what employers do with their new hires throughout the year and informing them well enough to keep enrollment consistent. A mechanical contractor White worked with about 10 years ago wondered why health plan utilization was so low among its blue-collar workforce spread across the Southeast – even with the right tools in place. A real worry was surfacing that a $3 million a year investment was being squandered. Upon closer review, the company decided to require that all employees attend a meeting to help them become better healthcare consumers – stopping short of tying eligibility for coverage to their attendance and instead incentivizing them to be there with financial rewards. As part of that effort, he explained to employees that they would not incur any out-of-pocket costs for choosing preferred imaging and outpatient surgical centers, as well as other facilities and exclusive avenues for obtaining specialty medications. “The key takeaway for any employer that is self-insured is to have a cadence with whoever represents you in the market to review your data and understand what new solutions are out there,” White says.

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An emerging tool for helping with open enrollment is the use of artificial intelligence, which can help not only with decision support but also create video presentations using a company HR director’s likeness and voice, White explains. AI illustrates the advantages of technology in helping craft creative, compelling and informative messaging. But despite these advances, he says there’s still a need for concierge services or some sort of advocacy for health plan members who face a multitude of challenges related to medical care, surgical procedures or medication management. “No video is going to explain that, and it’s too much weight on an HR team,” he cautions. Whatever medium is used, experts agree that self-insured employers and their vendor partners need to explain health benefits within a larger context. White tells clients all the time to approach OE in terms of handing their employees a credit card with a cap on spending that depends on where they set the retention on their stop-loss.

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“Everyone is trying to figure out how to educate their employees to be better consumers with that credit card,” he says, noting the importance of explaining why costs keep rising, especially to high utilizers of healthcare, so that they have a better understanding about what’s happening and appreciation for their benefits. Another strategy is to crack down on basic practices. One common problem Lee encounters is the prospect of careless errors, which can prolong open enrollment. “If employees are going to be covering their dependents, make sure they have the full name with the proper spelling, date of birth and Social Security number,” she says. “Most often, that’s one of the things that delays the openenrollment process.”

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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AI AND HEALTH PLANS: THE BEST OF TIMES, THE WORST OF TIMES

Written By Jeannie Comins-Roberts

harles Dickens famously opened A Tale of Two Cities with the words, “It was the best of times, it was the worst of times.” Nearly two centuries later, those words remain fitting for the conversation about artificial intelligence’s role in employer-sponsored health plans. AI has quickly moved from a futuristic concept to a practical health plan tool. It can support plan document drafting, claims analysis, appeals, cost containment reviews, administrative workflows, and member engagement. However, this rapid adoption also raises significant questions about transparency, accountability, privacy, bias, and public trust. The question for plan sponsors, administrators, third-party administrators, and advisors is no longer whether AI will become part of the health plan landscape—it already has. The real question is whether organizations will use AI to improve outcomes for plans and participants or allow efficiency goals to outweigh sound judgment, accountability, and participant protections.

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THE PROMISE: BETTER PLANS THROUGH BETTER INFORMATION

Health plans generate enormous amounts of information and content, including claims data, provider billing patterns, utilization trends, eligibility records, appeals, compliance requirements, plan documents, and vendor contracts. Because that volume often exceeds a human’s capacity for timely review, AI can provide tremendous value. AI can help identify patterns that would otherwise go unnoticed, detect unusual billing activity that may indicate fraud, waste, or abuse, and unearth potential savings opportunities. By directing qualified reviewers to claims that warrant further investigation, AI can help plans better understand where healthcare dollars are being spent and where intervention may improve outcomes. For example, an AI tool could identify a concentration of unusually similar billing patterns across multiple providers and route those claims to a special investigations unit. The tool would narrow the review population, while trained investigators would examine the underlying records, determine whether the pattern has a legitimate explanation, and decide whether further action is warranted. The question most often asked by plan administrators and fiduciaries is not whether they should use AI, but how they can use it to improve efficiency without compromising oversight, compliance, or participant protections. In plan administration, AI can support documentation, compliance, claims review, research, workflow management, and data analysis work via the following functions: ·

Reducing the amount of manual and mundane administrative work by streamlining workflows

Drafting and maintaining plan documentation

Comparing plan language across documents and amendments

Supporting claims and appeal reviews and population health analysis

Improving compliance monitoring

Analyzing plan data to identify operational trends and opportunities

Used appropriately, AI can spare skilled professionals from repetitive tasks and allow them to focus on judgment, strategy, member advocacy, and decision-making. AI can also help address talent gaps by increasing the bandwidth of experienced professionals, preserving institutional knowledge, and supporting teams when specialized expertise or staffing resources are limited. It should supplement—not replace—the qualified professionals responsible for final review and accountability. For example, a plan document team could use AI to compare a restated document with the prior version and flag inconsistent definitions, missing amendments, or benefit provisions that may require review. A qualified professional would then determine whether each difference reflects an intended plan design change, a compliance concern, or a drafting error before the document is approved. Beyond administrative efficiency, properly deployed AI may help plans identify lower-cost, higher-quality care options, improve healthcare navigation, and give members faster access to information and support— thus making plans more responsive and effective.

NOVEMBER 2026

AI SHOULD HELP US DO BETTER WORK, NOT JUST DO WORK FASTER

It seems logical to believe that the industry’s greatest mistake would be measuring AI solely by the number of hours it saves. Time savings, efficiency, and reduction of administrative costs all matter, but none of them is the reason health plans exist. Health plans exist to provide benefits, improve access to care, manage plan assets responsibly, and serve participants and beneficiaries. If an AI solution reduces administrative effort but produces poorer decisions, less transparency, or a diminished member experience, it has failed regardless of how much money it saves. The best opportunities are not in replacing people; they are in helping knowledgeable professionals make better, more informed decisions. AI can help identify trends faster, unearth potential issues sooner, and organize information more efficiently. What it cannot replace is judgment, context, and accountability. THE RISK: EFFICIENCY WITHOUT ACCOUNTABILITY

The excitement surrounding AI often focuses on what it can do. The more important question may be what it should do.

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Health plans operate in a highly regulated environment with real-world consequences for participants and beneficiaries. Decisions involving coverage, claims, appeals, access to care, and plan benefits cannot simply be delegated to an algorithm without adequate oversight. One of the greatest risks is treating AI as the final decision-maker rather than as a decision-support tool that informs—but does not replace—qualified human review. Experience shows that responsible implementation begins before an AI tool is put into use. Everyone involved should understand the tool’s intended purpose, the data it relies on, its limitations, and the appropriate way to interact with it. Because AI can produce inaccurate or fabricated information—often called hallucinations—organizations must define who will validate its outputs, how accuracy will be tested, and when human review is required before those outputs inform plan decisions or communications. Before adopting an AI solution, organizations should ask three practical questions: What specific problem are they trying to solve? Who remains accountable for the outcome? How will they test, monitor, and correct the tool when it is wrong? If an organization cannot answer these questions clearly, it is not ready to move from experimentation to implementation.

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Organizations should use extreme caution when AI influences benefits, claims, appeals, payments, eligibility, or legal rights. In these high-stakes processes, AI may provide information or recommendations, but qualified individuals must review the relevant facts, validate the output, and remain accountable for the final decision. For example, an AI system reviewing an appeal might summarize the claim history, identify the relevant plan provisions, and draft a preliminary response. The appeals specialist would still need to verify the facts, review the complete record, assess the participant’s arguments, and approve a response that accurately reflects the plan’s terms and applicable requirements. Public trust can erode quickly if members believe that decisions affecting their healthcare are being made by systems whose reasoning cannot be explained, whose outputs cannot be challenged, or whose owners cannot be held accountable.

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Not every administrative problem requires artificial intelligence. The goal should never be to replace professional judgment, but to augment it. In plan administration and document compliance, a clearer process, better-defined ownership, or stronger quality controls may sometimes solve the problem more effectively than another technological tool.

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TRUST WILL BE THE DEFINING ISSUE

If there is one theme that consistently emerges in conversations about AI, it is trust. There is good reason for optimism about AI because it can improve health plans in meaningful ways: identifying waste, strengthening operations and compliance, supporting plan administration, and helping members navigate a complicated healthcare system. Realizing those benefits, however, requires disciplined implementation and a clear commitment to member interests. The organizations that benefit most from AI will not necessarily have the most advanced tools. They will have the discipline to govern those tools well, clearly delegate responsibility, and keep member interests at the heart of every decision. Technology should enhance trust, not replace it. It should support better decisions without allowing organizations to avoid taking responsibility for them. Behind every claim, appeal, eligibility determination, and plan provision is a person seeking healthcare; keeping that reality at the center of each AI initiative is how the industry can realize the technology’s benefits while limiting its most significant risks. Members trust health plans to safeguard sensitive information and make fair decisions. Employers rely on vendors and advisors to protect plan assets and maintain compliance, while regulators expect organizations to understand the tools they use and the risks inherent in those tools. Responsible governance is what connects those expectations to practice. Organizations will also need to evaluate AI tools with the same rigor they apply to other critical vendor relationships. Business need, privacy protections, security controls, model performance, contractual protections, and ongoing oversight should all be part of the review process.

NOVEMBER 2026

For example, before deploying an AI-assisted member chatbot, an organization could limit it to approved educational content, prohibit it from making coverage determinations, test its responses against source materials, and establish a clear path to a qualified representative. The organization would also document who owns the tool, how errors are corrected, and when the tool must be suspended for review. For that reason, governance should not be treated as a secondary concern or a final implementation step; it should shape how an organization selects, tests, deploys, and monitors every AI tool.

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THE FUTURE BELONGS TO

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Some view AI as a replacement for human expertise, but that perspective misses the mark. The strongest health plans will combine AI’s breathtaking speed and scale with human judgment, empathy, experience, and accountability. AI may analyze thousands of claims, identify provider network patterns, or draft an appeal response in minutes. But it cannot independently assess the human impact of a coverage or payment decision, determine whether a solution satisfies fiduciary obligations, or assume responsibility for an accurate, compliant, and fair outcome.

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The most successful organizations will treat AI as a tool that supports stewardship—not as a substitute for the people accountable for plan assets, compliance, and participant outcomes. BEST OF TIMES OR WORST OF TIMES?

The opportunity is significant, but so is the responsibility. AI can reduce administrative burden, uncover cost-saving opportunities, and help members navigate a complicated healthcare system—but only when those benefits are pursued with transparency, accountability, appropriate oversight, and meaningful protections for patients and plan participants intact. If AI is used primarily to cut costs, automate consequential decisions, or remove human involvement where professional judgment is essential, public trust will erode. If it is implemented with clear governance, meaningful oversight, transparency, and a focus on better outcomes, AI can strengthen plan performance and member experience while balancing innovation with ethical, regulatory, safety, and privacy responsibilities. The future of AI in health plans will not be defined by the technology itself. It will be defined by the choices organizations make about how they use it. Those choices will determine whether AI ushers in the best of times or the worst of times for the health plan industry.

Jeannie Comins-Roberts is the Director of Plan Document Compliance at the Phia Group

NOVEMBER 2026

NEWS

NEWS FROM SIIA MEMBERS NOVEMBER 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. Executive Leadership Transition Announced at Caribou Caribou has announced a planned executive leadership transition that strengthens the company’s long-term strategic direction and positions it for accelerated growth. Richard Fleder, current Chief Executive Officer, will assume the role of Executive Chairman. Amy Gasbarro, currently serving as President, will advance into the role of Chief Executive Officer. This transition reflects Caribou’s continued momentum in independent pharmacy benefit management audit, payment integrity, fiduciary solutions, and transparency-driven innovation, areas where the company has established market leadership and deep client trust.

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NEWS “Caribou is entering an exciting new chapter, and this transition is a natural evolution of our growth,” said Richard Fleder, incoming Executive Chairman. “Amy has been instrumental in shaping our strategy, strengthening our operations, and building the culture that defines who we are. Her leadership, discipline, and vision make her the right person to guide Caribou into its next phase. I look forward to supporting her and the entire organization in my new role.” “I’m honored to step into the CEO role and continue building on the strong foundation our team and partners have created,” said Amy Gasbarro, incoming Chief Executive Officer. “We are fully aligned with this leadership transition and confident it positions Caribou for sustained growth and industry impact,” said Gordon Maner, Partner at Frontline Healthcare Partners. “Amy has demonstrated exceptional leadership and operational rigor, and her elevation to CEO reflects the strength of Caribou’s succession planning and strategic clarity. We look forward to continuing our partnership with both Amy and Richard as the company advances its next stage of innovation and expansion.” Rebranding Announced for Pinnacle Pinnacle Claims Management, Inc. announced its rebrand as Pinnacle Health Solutions, bringing its companies, including Pinnacle Health Management, together under one unified brand. According to a company statement, the new identity reflects Pinnacle’s continued evolution from its roots as a third-party administrator established in 1996 to a nationally competitive healthcare solutions organization serving the needs of self-funded employers. “Pinnacle has grown from a claims payor known for service excellence into a nationally competitive and innovative healthcare solution service provider,” said Steve Mangapit, President of Pinnacle Health Solutions. “Bringing our capabilities together under the Pinnacle Health Solutions brand gives us a clearer platform for delivering on what has always set us apart: trust, innovation, and a commitment to continually moving healthcare forward.” TMHCC Expands Sales Team with Sivigny Hire Tokio Marine HCC – A&H Group announced that Nichole Sivigny has joined the A&H Sales Team as Vice President, National Relationships. With more than 20 years of leadership experience in the Accident & Health insurance industry, Nichole brings extensive expertise in sales, underwriting, strategic growth, producer partnerships, and portfolio management. Throughout her career, she has built strong relationships across the industry and contributed to the growth and success of A&H businesses.

Nichole Sivigny

In her new role, Nichole will lead the strategy and management of key national producer and partner relationships, working closely with Sales, Underwriting, Account Management, and executive leadership to strengthen partnerships, drive profitable growth, and support strategic market opportunities. NOVEMBER 2026

NEWS Ryan McDonald Joins ClaimsBridge ClaimsBridge, a healthcare claims technology company serving TPAs, health plans, networks and other healthcare organizations, has named Ryan McDonald, CPA, Vice President of Finance.

Ryan McDonald

McDonald brings more than a decade of experience in accounting, finance and operational leadership. In his new role, he will lead financial strategy and operations for ClaimsBridge, helping support the company’s continued growth and investment in technology that simplifies healthcare claims administration and helps reduce healthcare costs.

Prior to joining ClaimsBridge, McDonald served as Vice President of Finance and Accounting at Cantey Tech Consulting, where he partnered with executive leadership to strengthen financial and operational processes and support long-term growth. His experience also includes healthcare technology, including time with XSOLIS. McDonald is a licensed CPA and earned both his Bachelor of Business Administration and Master of Accountancy from Belmont University. Boon-Chapman Names Justin Jobe as Senior Vice President, Sales Boon-Chapman announced the appointment of Justin Jobe as Senior Vice President, Sales. With more than 15 years of progressive sales leadership across the employee benefits industry, Justin brings a proven track record of exceeding growth objectives and building executive-level partnerships with brokers, consultants, and employer groups nationwide. In his role at BoonChapman, he will lead national sales strategy, deepen relationships across the company's broker and consultant network, and drive continued growth in the self-funded marketplace.

Dave Przesiek

Justin most recently served in a senior enterprise strategy role focused on captive and stop-loss growth, developing executive partnerships with brokers, consultants, TPAs, and employer groups nationwide and advising leadership on market strategy, product positioning, and competitive intelligence. Prior to that, he held sales leadership roles at Crumdale Partners and 6 Degrees Health, where he built strategic partnerships with TPAs and brokers and led RFP strategy, pricing, and implementation planning for complex healthcare accounts. He also served as Vice President, Sales Operations at East Texas Benefits, and began his career at CHRISTUS Health, where he worked in Medicare sales and account management within the highly regulated healthcare space. Justin brings a rare combination of deep industry expertise, national relationships, commercial discipline, and an entrepreneurial mindset that will be instrumental to our next chapter," said Kari L. Niblack, President of Boon-Chapman.

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NEWS Dave Przesiek to Lead Ryan Specialty Benefits Ryan Specialty Benefits has named Dave Przesiek as president and chief executive officer. The promotion moves Przesiek from chief revenue officer, a position he has held since joining through Ryan Specialty's acquisition of AccuRisk Holdings in December 2023. John Zern, who served as president and CEO since the division's formation, has departed to pursue other interests. Przesiek brings more than 30 years in the self-insurance market. He began his career across a series of health plan and third-party administrator roles before joining Fallon Health in 2010, where he spent a decade as a senior vice president overseeing product development and commercial sales. In 2020, he joined AccuRisk Solutions to lead the launch of its captive program, building out the medical stop-loss MGU's alternative funding capabilities before AccuRisk was absorbed into Ryan Specialty Benefits. His career has run almost entirely through the products RSB has built its platform around. Medical stop-loss, level-funded plans, and group captives for small to mid-market employers are all territory he knows from the inside. Pat Ryan, executive chairman of Ryan Specialty, said Przesiek had been "instrumental to the foundation of our benefits platform." The company did not disclose terms of the leadership transition. Rodney Dodson Takes on National Sales Role at PartnerRe PartnerRe announced that Rodney Dodson has joined the US Health Employer Stop-Loss team as Head of National Sales. Rodney joins PartnerRe from Elevance Health, where he served as Vice President, Stop-Loss Distribution, leading national distribution for its standalone stop-loss product. He previously held leadership positions at Voya Financial and brings more than 25 years of experience building and growing employee benefits and stop-loss organizations. "Rodney's deep industry expertise, strong producer relationships, and Rodney Dodson proven leadership make him an outstanding addition to our team," said Kelly Munger, Head of US Health. "His experience will be instrumental as we continue to grow our employer stop-loss business and strengthen our position as a trusted market partner." Cotiviti Announces New Chief Operating Officer Cotiviti has named Erin Schmuker as chief operating officer, bringing more than two decades of payment integrity experience to a company whose claims accuracy tools already run inside self-funded employer plans that a growing share of the US workforce depends on. Schmuker joins from Optum, where she most recently served as president of pharmacy care services beginning in November 2025. Her Optum tenure, which spanned nearly 17 years, included roles as chief executive Erin Schmuker 72

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NEWS officer of Optum Ireland and Optum UK from October 2023 to December 2025, and chief integration officer during a roughly $16 billion asset integration in 2022 and 2023. BRM Acquires Interactive Medical Systems BRM Specialty Markets (BRM) and Sands Point Risk, a diversified managing general underwriter, announced the acquisition of Interactive Medical Systems (IMS), a third-party administrator serving selffunded employers. According to a company statement, BRM and IMS bring together complementary expertise across medical stop-loss, healthcare risk underwriting and claims administration. By working together, the companies can more closely connect how healthcare risk is assessed with how claims are administered, providing clients with greater visibility and a more coordinated approach to managing healthcare costs and financial risk. “BRM and IMS are highly complementary businesses, but what makes this combination especially compelling is how similarly we think about serving clients,” said Roman McDonald, CEO of BRM Specialty Markets. “We believe in doing the work the right way, being accountable to our clients and finding smarter, practical ways to manage healthcare risk. We've built our business on understanding and pricing the financial risk behind healthcare. IMS sees how it plays out claim by claim. Bringing those capabilities together gives us earlier insight and better information to protect our clients’ healthcare dollars.” “This is a natural fit for IMS and our clients,” said Eric Ludwig, CEO of Interactive Medical Systems. “Our team sees firsthand how claims decisions affect an employer’s healthcare costs. Working more closely with BRM brings deep underwriting and risk management expertise together, giving our clients greater insight and a more coordinated approach to managing costs.” Michael Watson Named VP of Payment Integrity at Skyward Skyward Accident and Health has announced the appointment of Michael Watson as Vice President of Payment Integrity. In this role, he will drive payment integrity initiatives to uphold Skyward’s commitment to the highest standards of financial stewardship.

Michael Watson

With more than 30 years in the self-funded healthcare industry, Watson brings extensive experience to the role. He is a licensed life and health agent, a registered nurse (BSN), a certified case manager (CCM), and holds the Advanced Achievement in Transplant Management (AATMC) credential. During his career, he has successfully led large multidisciplinary cost-containment teams and built strategies to obtain savings. “Michael’s proven track record in innovative, proactive cost-containment strategies is a valuable asset to Skyward,” said Michael Remeika, Divisional President of Skyward A&H. “Additionally, his clinical and industry experience will be instrumental as we continuously bolster our payment integrity initiatives. Healthcare billing errors and abuse are widespread — making effective cost discipline an absolute necessity.”

NOVEMBER 2026

NEWS “I’m thrilled to join Skyward,” Watson said. “I’m very familiar with their solid reputation and dedication to higher standards in healthcare. I’m eager to work with such a talented team, be a part of its great culture, and bring my experience to the table as we focus on delivering exceptional value to our clients and partners.” Richard Fleder Joins ETS Board

Richard Fleder

Emerging Therapy Solutions® (ETS) announced that Richard Fleder has joined its Board of Directors.

Fleder’s appointment completes a two-position expansion of the ETS Board as the company continues to broaden its reach across the self-insured employer, payer and risk-bearing markets. His experience building and scaling organizations across the health benefits ecosystem brings an important commercial and strategic perspective as ETS expands CGT360™ and its broader high-cost complex-care capabilities. According to a company statement, Fleder brings decades of experience building, leading and advising companies across the self-insurance market. His background spans third-party administration, benefits consulting, stop-loss and reinsurance, pharmacy benefit management, specialty-drug cost containment and private equity-backed growth. “Richard is a proven entrepreneur and one of the most experienced and respected leaders in the self-insured market,” said Ashley Hume, CEO of Emerging Therapy Solutions. “He understands how employers, payers, carriers and advisors evaluate risk, build sustainable programs and bring innovative solutions to market. He also knows what it takes to build and scale companies in complex healthcare markets. That combination of industry knowledge, commercial judgment and entrepreneurial experience will be invaluable as ETS continues to grow and expand the impact of our solutions.” Andy Curry to Lead Health Solutions Underwriting at Captive Resources

Andy Curry

Captive Resources announced that Andy Curry has joined the company as Head of Health Solutions Underwriting (HSU). Curry brings more than 20 years of underwriting and leadership experience, with deep roots in medical stop-loss. He began his career at Sun Life Financial as a stop-loss underwriter before joining Tufts Health Plan, where his responsibilities expanded to include both fully insured and self-funded business. He later joined Berkley Accident & Health, where he led a team of stop-loss underwriters and supported underwriting operations and strategic initiatives. Most recently, Curry served as Vice President & Chief Underwriter at Blue Cross Blue Shield of Massachusetts, providing strategic direction across the organization’s commercial underwriting programs. 74

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NEWS During his tenure, his responsibilities expanded beyond medical stop-loss to include large employer, pharmacy, and retention underwriting, as well as product and pricing strategy and key carrier and reinsurance relationships. As Head of HSU, Curry will be responsible for underwriting strategy, technical underwriting, and underwriting operations, and will serve as a key point of contact for carrier partners. He will report to Steve Gransbury, President of Health Solutions, and join the Health Solutions Leadership Team. “Andy brings the combination of deep technical stop-loss expertise and broad underwriting leadership experience that will be incredibly valuable as we continue to grow Health Solutions,” said Gransbury. “His experience leading underwriting strategy and operations, coupled with his understanding of the broader healthcare landscape, will further strengthen our underwriting capabilities and the support we provide to our carrier partners, brokers, and members.” Scott Revey Takes Key Sales Position at IS Benefits Integrated Solutions for Benefits and Insurance Services (IS Benefits), a leading provider of stop-loss marketing and cost containment solutions for self-funded employers, announced the appointment of Scott Revey as Senior Vice President of Sales & Growth.

Scott Revey

Revey joins Integrated Solutions during a period of significant growth for the company and will lead its sales strategy, expand relationships across the self-funded healthcare market, and help bring Integrated Solutions’ stop-loss and cost containment solutions to a broader network of TPAs, brokers, consultants, and employers nationwide. Revey brings more than a decade of healthcare and employee benefits experience, with particular expertise in self-funded health plans, stop-loss, pharmacy benefits, specialty drug solutions, provider networks, and cost containment. Most recently, he served as Regional Vice President, Southeast, at Health Plans, Inc. (HPI), where he was a top producer and worked closely with brokers and consultants to develop self-funded solutions for employers. “Scott is exactly the type of leader we want to add as we build the next chapter of Integrated Solutions,” said Tyler Benware, CEO of Integrated Solutions. “He understands the self-funded market, has built tremendous relationships throughout the industry, and knows how to bring together brokers, TPAs, carriers, MGUs, and cost containment partners to create better outcomes for employers. More importantly, he shares our belief that growth should come from being a great partner and creating real value for the people we serve. We’re incredibly excited to have him on the team.”

NOVEMBER 2026

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2026

SELF-INSURANCE INSTITUTE OF AMERICA Board of Directors CHAIRWOMAN OF THE BOARD*

BOARD MEMBER

Amy Gasbarro CEO Caribou Systems

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 Brown & Brown Healthcare 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 General Manager, MHW Benefit Partners MedImpact

* also serves on the Board

CELL AND GENE TASK FORCE Ashley Hume President Emerging Therapy Solutions®

NOVEMBER 2026

SIIA NEW MEMBERS

2026

BOARD OF DIRECTORS

SILVER MEMBERS: Jamie Potecha COO Take Command Health Richardson, TX CORPORATE MEMBERS: Ralph Blackwelder CEO Enrollment Management Services Cincinnati, OH Daniel Boisvert CEO Member First Health LLC Hingham, MA Kelly Cromer Chief Pharmacy Officer PCARx LLC San Diego, CA Anastasia Lee Vice President EQT Group New York, NY Shawn Matheson Executive Director, Health System Operations Native Insurance Alliance Ivins, UT Ashley McConnell Executive & Operations Assistant ZERO Tulsa, OK Catherine Moesgaard SVP of Brand Growth & Marketing Embla Health Georgetown, TX

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Masha Polischuk Senior Manager, Marketing OrionRx Irvine, CA Peter Robinson Chief Executive Reinsurance Advisory Services San Francisco, CA Jeff Schaffer Chief Revenue Officer EHVAhealth Dorado, Puerto Rico Sarah Scheffsky COO Providers Health Solutions Monroe, LA Brandon Simon President and CEO Acuity Health Advisors Liberty Lake, WA Donal Tobin CEO Integrate.io Las Vegas, NV

EMPLOYER MEMBERS: Kristine Mutlak Administrative Assistant VSMG (Valley Schools Management Group) Phoenix, AZ

Dani Kimlinger CEO & Partner MINES & Associates Les Boughner Chairman Advantage Insurance Liz Midtlien Head of Large Claims Solutions BCS Financial Corporation Matt Hayward Office President Ryan Specialty Jonathan Socko President East Coast Underwriters, LLC Nigel Wallbank SIEF Chairman Emeritus

When bills get complicated, we’re in your corner Zelis Health Bill Assist helps employers support members with clear guidance, provider follow-up and expert advocacy. SM

Less confusion for members. More confidence for TPAs.

Scan to read how Zelis helped resolve a $51K health bill.

THE SELF-INSURER

Predictable by design. Managing claims uncertainty through reliable, precise payment execution. When it comes to paying high-dollar Stop Loss claims, predictability is everything. It’s confidence, security, and peace of mind. At HM Insurance Group, we’ve transformed a source of uncertainty into dependable performance. The result: payments made quickly with more than 99% technical and financial accuracy. Experience predictable claims management. 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 (4/26)

THE SELF-INSURER