Issuu

O C TO B E R 2 0 2 6

A S I P C P U B L I C AT I O N

Virtual Care

for Metabolic

Management & GLP-1 Prescribing

SIPCONLINE.NET

At the heart of expecting the unexpected

Accident & Health

Get the support it takes to overcome today’s self-insurance challenges. Self-funding your healthcare can offer greater control over costs, but only if you have the right partner to help make it happen.

Read now: 2026 Accident & Health Market Report

From more frequent stop loss claims and medical inflation to the rising costs of labor and specialty drugs, today’s market is full of changes and complexities. QBE stays up to date on those trends and tailors solutions to help you navigate them. Products we offer: Medical Stop Loss | Captive Medical Stop Loss | Organ Transplant We get to know your business inside and out and support it with deep, specialized expertise and collaborative claims and underwriting.

For more information, scan the QR code or visit qbe.com/us/msl

Specialty | Commercial | Crop All products and services are written or provided by QBE Insurance Corporation or its affiliates, 10 Terrace Court, Madison, WI 53718, and may not be available in all states. QBE and the links logo are registered service marks of QBE Insurance Group Limited. © 2026 QBE Holdings, Inc.

TABLE OF CONTENTS

OCTOBER 2026 VOL 215

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

F E AT U R E S 4

VIRTUAL CARE FOR METABOLIC MANAGEMENT & GLP-1 PRESCRIBING Written By Laura Carabello

MSK’S ESCAPE ROUTE Written By Bruce Shutan

ARTICLES 40

AI THAT CAN BE CROSS EXAMINED: BUILDING TRUSTWORTHY CLAIM DECISIONS IN THE SELF-INSURED MARKET

Written By Alston & Bird, LLP Health Benefits Practice

Written By Ashish Jaiman 50

THE DIGITAL HEALTH DILEMMA: WHAT’S WORKING AT WHAT COST

ERISA’S NEW FEE DISCLOSURE REQUIREMENTS FOR HEALTH PLAN SERVICE PROVIDERS

MEMBER NEWS

Written By Laura Carabello

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

OCTOBER 2026

F E AT U R E

Virtual Care for Metabolic Management & GLP-1 Prescribing

Written By Laura Carabello

elf-insured employers are painfully aware of the fastest-growing cost driver in employee benefits: GLP-1s, better known as weight-loss drugs. The obesity-drug competition is becoming less about losing weight and more about keeping it off and enhancing cardiovascular and metabolic health – termed cardiometabolic health. The conditions are closely intertwined, with high or unstable blood sugar levels contributing significantly to heart disease and stroke risk. Now, plan sponsors can’t afford to ignore the new generation of virtual care solutions that are reshaping how these medications are managed and discovering what's possible to better address these serious, highcost conditions. UNDERSTANDING THE DISEASE

When the body is unable to efficiently utilize food for energy or process blood sugar without medication, it becomes insulin resistant. This primary driver of the American cardiometabolic crisis has deepened as chronic health conditions—heart disease, diabetes, obesity, and kidney dysfunction—increasingly overlap, affecting a staggering 90% of adults to some degree. The American Heart Association attributes this shocking number to a newly classified CardiovascularKidney-Metabolic (CKM) syndrome, linking heart disease, kidney disease, diabetes and obesity. Now, experts link fatty liver disease to CKM, causing cirrhosis as well as increased risk of breast, colon and pancreatic cancer. 4

THE SELF-INSURER

Virtual Care SOCIOECOLOGICAL FRAMEWORK FOR CKM SYNDROME

Social determinants at multiple levels of influence, including at societal, community, interpersonal and individual behavioral levels, affect the likelihood of cardiovascular-kidney-metabolic (CKM) syndrome and of consequent adverse outcomes. Individual biological predisposition, nested within these multiple levels of social influence, further affects CKM syndrome development and related outcomes.

Source: Circulation. A Synopsis of the Evidence for the Science and Clinical Management of CardiovascularKidney-Metabolic (CKM) Syndrome: A Scientific Statement From the American Heart Association According to WTW’s 2024 Best Practices in Healthcare Survey, employers consider cardiometabolic disease a primary health concern: 84% said diabetes was a top health priority, while 83% cited obesity and 56% said cardiometabolic disease. This focus aligns with the increase in treatment utilization and pharmacy spend on these conditions.

OCTOBER 2026

“A HEALTH PLAN FOUNDED ON FAIRNESS? THAT’S HOW IT SHOULD BE.”

If being a champion for our members makes us Health Plan Rebels, so be it. Founded on fairness, we can help you cut costs by up to 33% compared to traditional health plans. Plus, we relentlessly advocate for our members and boast a 94% average provider acceptance rate. That sounds fair to us. Join us today.

claim-doc.com

Isaac Leanos Member Advocate

Virtual Care

EMPLOYERS BEAR THE BURDENS

Employers are increasingly aware of the impact of obesity upon the physical health of members and the financial toll on plan performance. Obesity is regarded as the anchor for CKM syndrome and according to a 2024 peer-reviewed study published in Nutrition & Diabetes, the combined economic burden of obesity and overweight among U.S. workers reached $425.5 billion in 2023, with the average cost per employee with obesity running $6,472 per year — compared to a healthy-weight counterpart. The same study found that for a hypothetical employer with 10,000 employees, obesity and overweight costs total $22 million per year for obesity alone. Further confirmation in a PubMed-published study found that medical expenses for employees with obesity are estimated to be 42% higher than for normal-weight adults. OCTOBER 2026

Virtual Care For self-insured employers, the math is truly unforgiving as the bills for these conditions simply mount, year after year. Cardiometabolic health is more than a wellness initiative; it's a financial imperative.

Source: Journal of Medical Internet Research. Network of core keywords related to MetS: metabolic syndrome. ENTER GLP-1 MEDICATIONS — AND THE UNAVOIDABLE COVERAGE QUESTION

GLP-1s such as semaglutide, tirzepatide and others have fundamentally changed what's medically possible for weight management. For example, the Institute for Clinical and Economic Review (ICER) affirms that Tirzepatide, an FDA-approved, once-weekly injectable medication that treats type 2 diabetes, obesity, and moderate-to-severe obstructive sleep apnea, regulates appetite, slows digestion, and stimulates insulin release. ICER maintains that Tirzepatide produced a mean weight loss difference of -17.8% versus placebo, and -20.2% versus head-to-head trials. A real-world study at an academic obesity clinic found that patients persistent on GLP-1s for 12 months achieved a median weight loss of 14.4%, approaching clinical trial results. For employees with type 2 diabetes, the cardiometabolic benefits are equally compelling. GLP-1 medications prescribed for obesity could generate nearly $193,000 in lifetime economic and health value per patient while delivering outsized benefits to populations that have historically faced greater barriers to weight management, according to a new working paper from the National Bureau of Economic Research. 8

THE SELF-INSURER

U N I VE R S I T Y

Virtual Care AMERICAN COLLEGE OF PHYSICIANS (ACP) RECOMMENDATIONS

Most recently, the ACP issued recommendations that semaglutide and tirzepatide are first-line treatments for overweight and obesity. They advise that clinicians and patients should discuss factors like harms and benefits, costs, values and preferences. ACP has published living clinical guidance to help physicians select medications for patients with overweight or obesity, saying the new guidance “addresses additional management using pharmacologic treatments when lifestyle modifications alone do not result in optimal weight loss or weight maintenance for a person.”

What’s truly incredible is a July 2026 Gallup poll showing the share of US adults currently taking GLP-1 medications for weight loss has climbed to 11% in 2026, up significantly from 3% in 2024. Moreover, 15% report having used the medicine for weight loss at some point, an increase of nine percentage points.

THE SELF-INSURER

IS OUR POLICY At BHSI, our policy is clear: Covered Employer Stop Loss claims are reimbursed quickly and accurately. CLAIMS IS OUR PRODUCT® and we have the stellar financial strength and industry-leading

Employer Stop Loss team to consistently do what's right for our customers - and do it fast. So you get balance sheet protection, with certainty.

bhspecialty.com/esl BERKSHIRE HATHAWAY SPECIALTY INSURANCE

Virtual Care But these medications come at a cost, carrying price tags that have forced self-insured employers into an untenable position: cover GLP-1s broadly and face unsustainable drug spend, or exclude them entirely and risk worsening health outcomes and workforce dissatisfaction. An Employee Benefit Research Institute (EBRI) study shows that GLP-1 drug claims among privately insured adults rose from 6.9% in 2023 to 10.5% in 2025, and now account for more than 15% of annual claims for more than a quarter of employers. Paul Deger, MA, LPC, LPCC, LMHC and chief clinical experience officer, TPN.health, advises, "GLP-1 medications sit at an interesting intersection for physical health, behavioral health, and social determinants like body image. On one hand, they can help close what I call the 'know-to-go gap': we all know we should eat better, move more, sleep well, but sustained behavior change is genuinely hard. If these medications support someone making that change more achievable, that's a real clinical win.”

Paul Deger

On the other hand, he says we have to ask whether they add to the pressures our culture already places on body image and self-criticism.

“My hope is that something this significant doesn't get treated as a quick fix, but instead opens up honest conversation,” continues the psychotherapist and clinical leadership consultant specializing in digital mental health ventures. “In the same way we're still learning to have healthy conversations about technology's role in our lives, we need that same intentionality here, so people can make informed choices for themselves and for the field." COVERAGE DECISIONS

There is a plethora of surveys hitting the media with a variety of findings:

• Last summer, an employer survey conducted by the Business Group on Health (BGH) found that 79%

of employers have seen an increase in covered members’ interest in weight management medications, including GLP-1s, as more employees qualify for coverage. While 96% of employers cover GLP-1s for diabetes, 67% are expanding coverage to include weight management, often struggling to manage costs and appropriate use. With this rising demand and broader eligibility, the overwhelming majority of employers are concerned about the long-term cost implications, highlighting ongoing challenges in managing overall drug expenses.

• A more recent survey from BGH found that the high cost of GLP-1s coverage for weight management is causing some employers to reconsider their decisions: 72% of those currently covering them say they’re likely to continue in 2027 and just 10% said they likely will not continue coverage for weight loss in 2027.

• Another study just in from the Pharmaceutical Strategies Group (PSG) across employers, health plans and unions paints a slightly different picture. This study reports 49% of payers who do not currently cover GLP-1s for obesity would not do so at any price.

THE SELF-INSURER

Virtual Care When asked the top reason for excluding coverage for obesity, 45% report coverage is too expensive for all members who would be prescribed the medication. Other factors include the view of the medications as lifestyle drugs (24%), ongoing cost exposure (18%) and high discontinuation rates resulting in a lack of ROI (5%). For plans that are open to GLP-1 coverage for obesity, the average amount they are willing to pay annually is $3,000.

• Yet another recent survey from the International Foundation of Employee Benefit Plans, spanning

31,000 multiemployer, corporate and public sector members representing over 25 million lives, shows the share of employers covering GLP-1s for both diabetes and weight loss has held steady at 36% year over year. Notably:

• Among employers that cover GLP-1s for at least one indication, 45% also cover the drugs for other FDA-approved conditions beyond diabetes and weight loss, while 55% do not.

• Among employers that only cover GLP-1s for diabetes or don’t cover them at all, 62% are not

considering adding weight loss coverage, 19% previously covered GLP-1s for weight loss but no longer do, 10% are not sure, and 9% are considering it. Wendi Mader, chief commercial officer, Cecelia Health, observes, “The trend is extending beyond obesity treatment and appropriate use of GLP-1 medications to comprehensive metabolic health management. Employers increasingly recognize that virtual care enables efficient clinical evaluation, medication eligibility assessment, and ongoing care while reducing barriers such as provider shortages, scheduling challenges, and geographic limitations. The greatest value comes from virtual care solutions that combine medication management with ongoing lifestyle, nutrition, and behavioral support from clinicians rather than medication access alone.”

Across the employee benefits community, it appears that stop-loss carriers and benefits consultants are changing their viewpoint of GLP-1s from a catastrophic claims threat to a pharmacy cost-management challenge. This shift parallels the 2026 Amwins Benefits State of the Market report, estimating that some employers are adding 2% or more to their healthcare budgets solely to account for GLP-1 medications. Many employers are bracing for expanded access to the drugs and accelerated utilization as new formulations, including oral GLP-1s, become available and for growing evidence that the drugs could improve long-term health outcomes and potentially reduce overall medical spending. Wendi Mader

Here’s a unique suggestion: CookUnity, the first chef-to-you delivery service for busy people who want to eat well, has developed the GLP-1 Employer Cost Calculator to estimate how coverage could affect your health plan and explore strategies for supporting long-term metabolic health across your workforce. Access here: https://www.cookunity.com/business/glp-1-coverage-employers-calculator.

OCTOBER 2026

Virtual Care NEW MEDICARE BRIDGE PILOT IMPACTS EMPLOYERS

Here’s a new wrinkle: The launch of Medicare's GLP-1 Bridge pilot is expected to reshape employer healthcare strategies as eligible participants now have access to certain GLP-1 medications for $50 per month. With millions of Americans aged 65 and older remaining in the workforce, employers will no doubt see the use of GLP-1s increase among this population. Eligible participants are those enrolled in Medicare drug coverage (Part D) with a body mass index (BMI) of 35 or more, or a slightly lower BMI accompanied by at least one other weight-related condition. WHAT’S THE BUZZ ABOUT COMPOUNDED GLP-1 MEDICATIONS?

Compounded GLP-1 medications are prepared by compounding pharmacies, usually at a lower cost than branded alternatives. Speaking at the 2026 J.P. Morgan Healthcare Conference, panelists reported that as many as 1.5 million patients in the U.S. may be using compounded versions of blockbuster GLP-1 drugs, underscoring how cheaper, unapproved alternatives have captured a significant share of demand for obesity treatments.

When the stop-loss market tightens, underwriting matters more. Stop-loss is being tested. Volatility is rising. Rates are under pressure.

UNDERWRITING M A N AG E M E N T EXPERTS

UME was built for this moment. Our stop-loss capabilities are grounded in disciplined underwriting, real claims intelligence, and structures designed to withstand market shifts. We help brokers and TPAs navigate risk — not react to it. Transparent underwriting you can explain

Data-driven risk evaluation

Flexible Plan Structure

Captive-ready strategies

Responsive, experienced support

Let's talk strategy.

THE SELF-INSURER

sales@umexperts.com

Virtual Care But according to the U.S. Food and Drug Administration (FDA), while compounding pharmacies were legally allowed to make copies of brand-name GLP-1s during national drug shortages, those shortages have been resolved. GoodRx reports that compounded GLP-1s have been largely phased out, although they may still be on the market for workarounds such as non-standard doses and forms. Moreover, the FDA has expressed concerns with compounded GLP-1s and has received reports of adverse events related to compounded versions. Consequently, the FDA ruled that pharmacies can no longer mass-produce standard "copies" of FDAapproved drugs. However, under certain conditions, pharmacies can still legally mix customized versions if a prescriber alters the drug’s dosage, ingredients (e.g., adding Vitamin B12), or for a patient with a unique medical need. The FDA has also issued numerous warning letters to telehealth companies that have made false or misleading claims about compounded GLP-1 products in their advertisements, including claims suggesting their products are the same as FDA-approved GLP-1 drugs. The FDA will continue to enforce compounding restrictions and prevent cheaper compounded alternatives from reaching the market. Benefit advisors at Sequoia say employers and patients might consider compounded versions for significant cost savings, but these medications call for careful consideration. Employers should seek compounding pharmacies accredited by reputable bodies such as the Pharmacy Compounding Accreditation Board (PCAB). From a pharmacist’s perspective, they advise that compounded GLP-1 medications present several risks: Safety risks: Potency can vary significantly between batches, increasing the risk of suboptimal dosing or overdose. Past documented issues have included contamination and improper storage, leading to serious adverse reactions. Efficacy risks: Lack of formal clinical testing means effectiveness can vary. Degradation due to improper storage, lack of bioequivalence studies, and absence of structured safety monitoring programs such as REMS or post-market surveillance may result in unpredictable clinical outcomes. Degradation due to improper storage and absence of bioequivalence studies may result in unpredictable clinical outcomes. Regulatory and legal risks: Compounded medications do not have FDA approval, potentially exposing employers to liability under ERISA and pharmacy benefit management contracts. RISKS OF MICRODOSING

Microdosing, as popularized by direct-to-consumer companies that sell compounded products that are not FDA-approved GLP-1 therapies at lower costs, poses risks. Many experts believe that compounded products sit outside FDA approval for a reason. Without the clinical trial data that backs approved therapies, neither the employer nor the patient has a reliable basis for evaluating safety, efficacy or appropriate dosing. Jonathan Wiesen, MD, cofounder & chief medical officer, Medi Orbis, concurs, “Regarding microdosing via compounded, non-FDA-approved GLP-1 products, this practice lacks clinical evidence and regulatory oversight. Physicians have an obligation to steer patients exclusively toward FDA-approved therapies with established safety and efficacy profiles.” OCTOBER 2026

Virtual Care Mader agrees that the clinical evidence supporting GLP-1 microdosing remains limited, and no FDA-approved GLP-1 therapies are currently indicated for this approach. “Employers should carefully evaluate programs that rely upon compounded products or dosing strategies without established clinical evidence or regulatory oversight,” counsels Mader. “Medication decisions should be guided by qualified healthcare professionals using evidence-based clinical guidelines, approved prescribing information, and each member’s individual clinical needs. As with any emerging treatment approach, clinical outcomes and patient safety should take precedence over marketing claims or Dr. Jonathan Wiesen perceived cost savings. Virtual care creates value when it extends access to evidence-based, clinician-led metabolic care—not when it simply makes GLP-1 prescriptions easier to obtain.” VIRTUAL CARE CHANGES THE LANDSCAPE

Virtual care platforms purpose-built for metabolic management are a smart strategy. For self-insured employers, they unlock several advantages traditional benefits structures can't provide, bringing clinical oversight, behavioral support and prescribing capability together in a coordinated, digital-first model. These solutions are designed to augment, complement, or replace GLP-1 prescribing with additional support services. Most solutions evolved from virtual cardiometabolic programs or telemedicine platforms that expanded their capabilities to incorporate GLP-1 prescribing and management. Dr. Wiesen observes, ”Employers are increasingly recognizing telehealth as an essential benefit for weight management, utilizing remote evaluations to efficiently capture comprehensive medical histories and facilitate evidence-based GLP-1 prescribing for qualified members.” He maintains that high-quality virtual platforms must start with clinically excellent programs that support prior authorization requirements and pharmacy coordination, as navigating these pathways meaningfully impacts medication access and adherence. “Equally critical is longitudinal care and clinical oversight — systematic monitoring of side effects, precise dose titration, and thoughtful tapering protocols distinguish clinically rigorous programs from transactional prescribing models,” he continues. “The integration of coaching and engagement tools, both synchronous and asynchronous, is essential to optimize the user experience and clinical outcomes. “ Melinda Alba, MD, chief medical officer, Evidium, Inc., confirms that employers are moving in this direction for good reason.

THE SELF-INSURER

Heading to Phoenix? Stop by our booth to learn how Valenz is transforming how healthcare is experienced, managed, and paid for.

Virtual Care “Telehealth services have been expanding since their inception, initially treating common urgent care illnesses,” she explains. “Opportunities to treat and manage chronic diseases, including hypertension, diabetes and obesity, are now more accepted and utilization of these services is rising. Patients have more opportunities to return to manage their condition as well as check in early to discuss medication side effects or other related concerns.” She says this is positive for both patient and provider, adding, “As a clinician, this gives us the opportunity for early intervention, managing side effects, adjusting dosing and providing patient education. For the patient, virtual care is an opportunity to have questions answered by their trusted source of medical information in an expedited manner.” Dr. Alba maintains that the limitations of services when it comes to GLP-1s are around the prior authorization. “Initially, the indications to prescribe a GLP-1 were very limited to people Dr. Melinda Alba with diabetes,” she continues. “This directly impacted prior authorization, especially when we were seeing weight loss as a side effect. For wellestablished virtual care platforms, a prior authorization process was in place, which obviously resulted in fewer unhappy clients, as these were able to facilitate the process. The patient's experience was evident in how quickly they received their prescription.” Now, as GLP-1 indications expand, Dr. Alba believes that the authorization process is improving. “It remains a key component for positive interactions with the telehealth platform. The best-case scenarios include both prior authorization and pharmacy support.” Beckie Fenrick, PharmD, chief pharmacy officer, Navion, affirms that many weight management solutions offered to employer groups now include telehealth and video consultations as a core component.

Beckie Fenrick

“These programs typically pair GLP-1 prescribing with a multidisciplinary care team: dietitians, health coaches, and clinical professionals such as advanced practice nurses and physicians — who support patients throughout their weight management journey. That comprehensive model is what makes the difference: not just access to medication, but the ongoing support and monitoring that help members make sustainable lifestyle changes for long-term results.”

She attests that both prior authorization and pharmacy support for weight loss medications are essential components of a virtual care platform, adding, “Real-world data shows more than 50% of GLP-1 users discontinue therapy within a year, with side effects, including nausea, GI issues, and hair loss, among the leading reasons. Prior authorization tied to documented medical necessity supports appropriate patient selection from the start. Ongoing monitoring matters just as much: patients who stop therapy can regain a significant portion of lost weight rapidly, making tapering decisions and

THE SELF-INSURER

Virtual Care continued clinical support a critical part of any responsible program.” Fenrick emphasizes that the clinical evidence is clear: sustainable weight loss depends on long-term behavior change, not medication alone. “Programs offering diet, exercise, and lifestyle support alongside GLP-1 therapy improve outcomes and help patients maintain progress after stopping medication,” she emphasizes. “A virtual program that prescribes without that wraparound support isn't managing metabolic health. It's managing a prescription.” Recognizing that a prescription alone isn't enough, Becca Bean, senior vice president, DialCare, advises, “When employers are looking at GLP1 solutions, they really need to demand a model where their employees receive ongoing communication from both prescribing doctors and behavioral health experts,” she says. “Our Virtual Primary Care model provides whole-health support and preventive care services. Licensed physicians conduct initial evaluations, prescribe medications, provide pharmacy support, monitor clinical side effects and manage dosing.” But she maintains that the medical aspect is only part of the solution, noting, “We believe members also need the benefit of working with Becca Bean behavioral support experts who can provide guidance on crucial nutritional and lifestyle factors. It's a two-part approach that maximizes metabolic benefits and creates real, sustainable health outcomes for every employee served by virtual care platforms that provide access to GLP-1 medications.” CAUTIONARY GUIDANCE

Telehealth platforms offer virtual medical evaluations and medication management, while retail health options and direct-to-consumer platforms integrate online consultations directly with prescription deliveries. Because GLP-1s carry potential side effects, they require a prescription and should only be obtained through legitimate services with licensed healthcare professionals. Providers must be licensed in the specific state for virtual care and must conduct a thorough medical review before prescribing. Traditional primary care physicians have expressed concerns that some thirdparty telehealth companies provide rushed evaluations or poor long-term monitoring. To ensure safe prescribing and delivery, major pharmaceutical manufacturers have launched direct digital networks to connect patients with telehealth providers and medications. In a study published in the Journal of the American Medical Association, one researcher at Yale University set out to document those online prescriptions by posing as a ‘secret shopper’ patient. The results capture what many Americans have learned in the last few years: It is extraordinarily fast and easy to get a GLP-1 online. Forty-five of 49 sites wrote a prescription for the patient, whose simulated profile included obesity and prediabetes — usually within a day, and sometimes in less than five minutes. But the prescription process often fell short of obesity care standards. Many telehealth sites’ patient intake surveys skipped essential 20

THE SELF-INSURER

Virtual Care questions about eating disorders and lifestyle. Steps to verify patients’ self-reported information were poorly enforced. In some cases, the patient received multiple prescriptions from the same clinicians working for different sites. Now there are specific allegations against telehealth company LifeMD, listed as a provider on the Novo Nordisk website, the maker of Ozempic and Wegovy. The complaints claim that the company has sought to maximize the volume of prescriptions it issues at the expense of patient safety, which has led to reckless prescribing. While LifeMD strenuously denies the charges, these concerns come amid growing concerns about lax clinical oversight of telehealth providers, as referenced earlier. MULTIPLE ADVANTAGES OF THE VIRTUAL APPROACH

Clinical gatekeeping that protects plan members and the bottom line. Wraparound support optimizes clinical outcomes. The greatest risk with GLP-1 coverage isn't the medication itself; it's providing coverage without having a clinical structure in place. When care is left unmanaged, reports show that 40–50% of members are placed directly on a GLP-1 as a first-line treatment. Virtual metabolic programs with structured prescribing protocols bring that number down dramatically: one program reported only 14% of members starting on a GLP-1, with the rest beginning with behavioral and less intensive interventions. This keeps your benefit justifiable and cost-effective.

The Best TPAs Have Nothing to Hide. Looking for transparent, accountable health benefits administration? Learn more about the right questions to ask your TPA partner.

novahealthcare.com

OCTOBER 2026

Virtual Care Dr. Wiesen advises employers that are evaluating virtual programs to demand seamless communication with primary care physicians, registered dietitians, nutritionists and fitness specialists, noting, “This interdisciplinary infrastructure transforms GLP-1 therapy from a pharmacological intervention into a comprehensive metabolic reset,” he says. GLP-1 medications work best when paired with nutritional coaching, behavioral health support and lifestyle modification. Research published in the Cleveland Clinic Journal of Medicine found that combining GLP-1 medications with intensive lifestyle intervention in a real-world virtual program led to sustained weight loss — yet fewer than 2% of qualifying adults currently receive GLP-1s alongside structured behavior change support. Omada Health's internal data found that members in their Enhanced GLP-1 Care Track who persisted on medication through 12 months experienced an average weight loss of 18.4%, compared to 11.9% in realworld evidence without structured support. ONLINE MEDICATION ORDERING

KFF polling data shows that while most patients who have taken a GLP-1 received their prescription through a primary care doctor or a specialist, some industry observers are concerned that getting a weight loss prescription online is usually much easier than getting one through an in-person appointment. Many telehealth companies write quick prescriptions for GLP-1s, but they often sell the medications, too, allowing patients to bypass in-person pharmacy visits. Critics maintain that this one-stop shopping may not be a positive trend, charging some telehealth providers with writing prescriptions for people who should not be taking GLP-1s and then providing little or no follow-up care. Virtual care visits may present an easy way to lose weight, especially with a boost from paid celebrity endorsements, but often fail to emphasize the importance of healthy eating and exercise, KFF Health News review of Food and Drug Administration data, along with telemedicine researchers, worries that adverse experiences tied to telehealth companies are becoming more common. But suboptimal outcomes aren’t unique to telehealth providers or to the compounded weight loss drugs many of them offer. In fact, court data shows that product liability lawsuits alleging patient injuries have been filed overwhelmingly against pharmaceutical giants that manufacture name-brand weight loss drugs. INTEGRATED FORMULARY AND UTILIZATION MANAGEMENT

A truly effective virtual care partner acts as an extension of the benefits team, actively navigating the complexities of GLP-1 therapy. The right virtual care partner will work within your pharmacy benefit structure, applying step therapy protocols, prior authorization logic, and manufacturer coupon strategies to reduce per-member drug costs without restricting access for clinically appropriate candidates. Mader attests that prior authorization and pharmacy support are essential components of a high-quality virtual care program. ”…because they help members access appropriate therapies efficiently while ensuring alignment with employer benefit design.”

THE SELF-INSURER

Virtual Care But medication access is only the starting point, as Mader emphasizes, “Sustainable outcomes require ongoing clinical oversight, including dose titration, side effect monitoring and management, adherence support, and individualized planning for long-term maintenance or medication discontinuation when appropriate, plus coordination with prescribing providers. This continuous engagement not only promotes safety and effective medication use but also helps members remain engaged in the lifestyle changes necessary to achieve lasting metabolic health improvements.” She advises employers to evaluate virtual care programs based on the quality of clinical care they deliver— integrating medication management with lifestyle interventions, intensive nutrition counseling, physical activity, and psychosocial support to drive lasting metabolic health improvements. “Effective programs are clinician-led and supported by multidisciplinary teams that include registered dietitians and specialty providers as appropriate,” Mader explains. “Equally important is communication with primary care providers to ensure care is coordinated and sustainable. Employers should look for demonstrated clinical outcomes, sustained engagement, evidence-based protocols, and integrated care models that help members build healthy behaviors alongside appropriate medication use.”

The integrated TPA platform built for self-insured health plans SELF-INSURED EMPLOYERS

One connected system for care, claims, and compliance Most self-insured plans run claims, care, and reporting on separate systems. That disconnection creates errors, audit risk, and administrative burden your team absorbs every day.

Care Compass connects enrollment, claims adjudication, and compliance reporting in a single system — so your team stops reconciling across vendors and starts running a tighter operation.

PILLAR 1

PILLAR 2

PILLAR 3

Compliance built into daily work

One system, not a stack of vendors

A foundation that scales with you

Audit trails, regulatory reporting, and discrepancy detection embedded in every workflow — not a separate process at audit time.

Claims adjudication, provider payments, enrollment, and care management all run on the same platform. No duplicate entry. No data gaps.

Add programs, grow census, or expand services without replatforming. 30 years of complex care experience behind it.

See it in Action

ppi.com

THE SELF-INSURER

30+

13K+

YEARS MANAGED CARE

PROVIDERS SUPPORTED

#1 LARGEST U.S. PACE ORG IS A CLIENT

Virtual Care ASYNCHRONOUS AND SYNCHRONOUS CARE OPTIONS.

Not every employee can or will attend in-person appointments. Virtual metabolic programs meet members where they are, through app-based check-ins, telehealth visits and on-demand messaging with care teams. According to WTW's 2024 Best Practice Survey, 38% of employers have already partnered with a thirdparty point solution vendor to support obesity management, reflecting growing recognition that medication alone is not the answer. Dr. Alba’s viewpoint is thoughtful: “Patient-centered coordinated care is complete virtual care. This allows for more dialogue and putting the patient first.” She emphasizes that care coordination is one of the most challenging aspects of patient care, explaining, “Therefore, virtual care that includes support not only from primary care physicians but also from wellness experts including dietitian and nutritionists, is important. With GLP-1's, assisting in the creation of healthy food regimens is a priority while controlling food cravings. Further, having a fitness expert available completes the coaching with weight loss. Whenever possible, the initial fitness training should be offered in person to ensure correct form and optimal weights. ADHERENCE TO TREATMENT IS KEY TO ROI

As with most treatment regimens, compliance with GLP-1 protocols is essential to improving clinical outcomes. When patients stop taking these drugs, studies show they not only regain weight, but also incur increased risk of heart attack, stroke and death compared to staying on the medication. Researchers at Washington University School of Medicine in St. Louis followed more than 333,000 U.S. veterans with type 2 diabetes for three years. Over the course of the study, 26% of GLP-1 users stopped taking the medication most often due to cost, side effects or lack of clinical support. About 23% had an interruption of six months or more followed by resuming treatment. Compared to continued use, they found that stopping or interrupting GLP-1 treatment for as little as six months was linked to a significant increase in the risk of major cardiovascular events. The longer the gap in treatment, the bigger the jump in risk — up to a 22% increase for cardiovascular events, even death -after two years off GLP-1s, largely erasing the benefits gained during treatment. Clearly, without adherence to treatment, members relinquish the outcomes they anticipate, and plans forego the downstream claims savings they need. COMPREHENSIVE V. WRAP-AROUND VIRTUAL SOLUTIONS

Today, some companies are partnering with employers to design custom programs based upon an employer’s benefit strategy, existing coverage dynamics and employee needs. The Peterson Health Technology Institute explains that typically, employers can choose either a comprehensive solution that includes a GLP-1 prescriber network paired with weight management and support services or a wraparound solution that provides additional weight management or support services to patients already receiving GLP-1 medications. OCTOBER 2026

Virtual Care The difference lies in the level of clinical integration and holistic care, as vendor offerings are evolving quickly in response to market trends and purchaser needs. Comprehensive Solutions integrate medications for weight management with broader cardiometabolic support, treating obesity as a chronic, complex disease rather than focusing solely on a calorie deficit. Offering a holistic baseline that combines nutrition therapy, exercise plans and behavioral counseling from day one, this approach establishes multi-faceted, foundational structures addressing diet, movement, behavior change and medical/surgical interventions simultaneously. They provide employees with access to clinicians and lifestyle counseling delivered by coaches or dietitians. This approach pairs access to prescriptions and medication management with structured behavior change programs. Prescriber integration enables these solutions to offer their behavior change programs as a stand-alone, weight loss option that can be used instead of a GLP-1 or as a complementary support for those receiving medication.

Source: NY Choice Medical Northwell Health points to the benefits of not simply achieving long-lasting weight loss but also overall health improvement. Employing a holistic strategy, comprehensive programs offer individualized treatment plans with a personalized approach that is tailored to a person’s unique needs, metabolic rate, medical history and personal preferences to ensure more effective and sustainable weight loss. They take into account multiple aspects of weight loss including diet modification, physical activity, behavior change therapy and use of weight loss medications.

THE SELF-INSURER

Inspiring Confidence Accelerating Progress

ANNUAL MARKET REPORT Tokio Marine – A&H Group A member of the Tokio Marine HCC Group of Companies TMHCC1310 - 05/2026

HCC Life Insurance Company operating as Tokio Marine HCC – A&H Group For producer use only. Not for public distribution.

Scan to Read

HCC Life Insurance Company operating as Tokio Marine HCC – A&H Group

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

Tokio Marine HCC – A&H Group A member of the Tokio Marine HCC Group of Companies TMHCC-1339- 10/2026

Visit us online at tmhcc.com/AHGroup #TMHCC_AHGroup For producer use only. Not for public distribution

Virtual Care Experts at Northwell also point to the value of medical supervision, as these programs are overseen by healthcare professionals who are specifically trained in medical weight loss. They integrate care with onsite nutritionists and mid-level providers, further assuring that the weight loss process is safe, healthy and adjusted based upon progress and any medical issues that may arise. Collectively, these features focus on sustainable lifestyle changes, providing ongoing support and education to ensure long-term success. Members will develop healthy habits that can be maintained long after the formal program ends as opposed to quick-fix diets. It’s a recipe for reducing the risk of chronic diseases such as diabetes, heart disease and hypertension and enhancing quality of life, improved mobility and better psychological well-being. AT A GLANCE

Feature Primary Focus & Structure

Medical Oversight

Cost Focus

Comprehensive

Wrap-Around

All-in-one, provided by the External, managed by your own PCP; platform; The entire obesity Supplemental services wrapping around a management experience: diet, medication or surgical benefit. behavioral health, physical activity High; routine labs and Low; relies on your personal doctor medication management included Usually higher -- often requires Variable -- many offer free or low-cost monthly subscriptions tiers Holistic medical, behavioral, and Behavior modification, tracking, and nutritional changes lifestyle coaching

YOU CAN ONLY MANAGE WHAT YOU CAN SEE. Aphora gives self-insured employers greater visibility into pharmacy claims, spend, and utilization while working alongside the existing pharmacy benefit. $0 copays on covered prescriptions Human Care Navigation No PBM change required SCAN HERE TO GET A NO-COST SAVINGS ANALYSIS See how much Aphora could save your plan at AphoraHealth.com No tricks. Just clarity.

THE SELF-INSURER

Virtual Care Wraparound Solutions focus on supporting employees who are already receiving GLP-1s, but do not provide prescribing services themselves. Employers often adopt these programs when they use other GLP1 prescribing solutions or if they allow GLP-1 access through their standard pharmacy benefit and provider network. Essentially, they complement existing healthcare services rather than replacing them, “wrapping” additional support around the foundation of care a member already receives from their primary care physician (PCP). Members get their prescriptions and primary medical clearances directly from their own doctor. The virtual platform then provides supplementary services, such as digital food logging, mindfulness coaching, fitness tracking and dietitian support. This approach is ideal for those who already have a trusted PCP managing their medical weight loss and just need supplementary accountability, education or lifestyle coaching. This model effectively addresses common barriers to medication adherence by offering behavioral coaching, nutritional counseling, side-effect management and digital tracking tools. A number of solutions focus on food and nutrition, some of which include food

delivery and meal preparation services. Many solutions are also willing to offer performance guarantees and link payments to weight loss outcomes. A recent clinical trial shows that taking medications along with participation in the WeightWatchers behavioral program is 54% more effective for weight loss than reliance on medications alone. Sponsors of the program say adherence is key to successful weight loss with GLP-1s, and a wraparound program improves medication adherence by providing added support and motivation. When employees face challenges like navigating side effects or out-of-

EXPERIENCE YOU CAN COUNT ON. SOLUTIONS YOU CAN TRUST. In a market where many stop loss providers compete on price alone, StarLine delivers something more valuable: access, expertise, and solutions. Our underwriting team works directly with producers and their clients to understand each risk, develop creative structures, and deliver customized stop loss solutions that fit your client’s needs.

starlinegroup.com (508) 495-0882

CREATIVE UNDERWRITING. DIRECT ACCESS. REAL SOLUTIONS.

OCTOBER 2026

Virtual Care pocket costs, a wraparound program can provide ongoing education and encouragement to help them stay motivated and committed to their weight health goals. GROWING REGULATORY SCRUTINY

For the public “heavyweights” and venture capital-backed startups that have surfaced to meet overwhelming demand for GLP-1 weight loss drugs, the emerging state crackdowns on corporate medicine are a concern. Online care is caught in the crossfire as more than 30 states have determined it’s illegal for corporations to practice medicine. In fact, in the last two years, several states have moved to strengthen the corporate practice of medicine laws that govern relationships between physician-owned medical groups and lay companies. These regulations and proposals are written with an eye toward in-person care provided in hospitals, physician clinics, and nursing homes, and aim to protect patients from profit-motivated care. But the business model they target is also the underpinning for many telehealth companies as new lawsuits threaten their existence. 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

Do you aspire to be a published author? We would like to invite you to share your insight and submit an article to The Self-Insurer! SIIA’s official magazine is distributed in a digital and print format to reach 10,000 readers all over the world. The Self-Insurer has been delivering information to top-level executives in the self-insurance industry since 1984. Articles or guideline inquires can be submitted to Editor at Editor@sipconline.net The Self-Insurer also has advertising opportunities available. Please contact Shane Byars at sbyars@ sipconline.net for advertising information.

THE SELF-INSURER

Celebrating the past. Powering the future. Fifty years ago, we made a promise: to stand by our customers and partners by delivering financial protection they can count on. Today, that promise is stronger than ever. With innovation driving us and relationships guiding us, we’re here to lead and help shape the next 50 years of smarter, more resilient self-funded health care plans.

Learn how Symetra Stop Loss can help protect your self-funded plan. Visit us at symetra.com/stoploss50.

Symetra Life Insurance Company is the parent company of First Symetra National Life Insurance Company of New York (collectively, ‘Symetra’). Symetra Life Insurance Company does not solicit business in the state of New York and is not authorized to do so. Each company is responsible for its own financial obligations. Stop loss policies are insured by Symetra Life Insurance Company (est. 1957), 777 108th Avenue NE, Suite 1200, Bellevue, WA 98004-5135. Products are not available in all U.S. states or any U.S. territory. In New York, stop loss policies are insured by First Symetra National Life Insurance Company of New York, NY (est. 1990). Mailing address: P.O. Box 34690, Seattle, WA 98124. Coverage may be subject to exclusions, limitations, reductions and termination of benefit provisions. Symetra® is a registered service mark of Symetra Life Insurance Company. SLM-6349 5/26

F E AT U R E

MSK’s Escape Route

With musculoskeletal claims adding up, a more measured approach is needed to find the right treatment paths

Written By Bruce Shutan

usculoskeletal injuries, the nation’s leading cause of disability, have become increasingly common, exacerbated by an obesity epidemic and systemic failures. It’s no surprise then that these conditions, described in clinical shorthand as MSK, are top of mind for self-insured employers.

The prevalence of MSK is astonishing. As many as 126.6 million U.S. adults (about half the population) live with one of these conditions, according to survey data published by the United States Bone and Joint Initiative.

A single MSK injury is estimated to cost anywhere from $15,000 to $85,000, with indirect costs potentially doubling or tripling that amount. The National Safety Council estimates that employers spend nearly $18 billion a year in terms of workers’ compensation, lost productivity, absenteeism, presenteeism, turnover and recruitment impacts. One medical journal projects a roughly 115% increase in MSK cases between 2020 and 2050 – reaching more than a billion. “Honestly, for most self-funded employers I talk to, MSK is at or near the top of the list every year – usually right up there with, or ahead of, diabetes and heart disease,” reports Arpit Khemka, CEO and co-founder of SimpleTherapy, noting that it’s both common and expensive. What irks him most is how much of that spending didn’t need to happen. One major culprit is how care gets sequenced. When someone tweaks his or her back, he says imaging, injections and surgery are emphasized before conservative, movement-based care. “For a self-insured plan, every one of those avoidable procedures is money out the door,” he says. “Better outcomes and lower cost aren’t a trade-off here – they come from the same lever.” 32

THE SELF-INSURER

MSK's Escape Route JAGGED TREATMENT PATHWAYS

While most benchmarks list MSK costs as one of the top three drivers for self-funded health plans at 15% to 20% of overall costs, Regenexx, LLC Executive Vice President Mark Testa notes that about half of that spend goes toward elective orthopedic surgeries. He says some are low value, citing as examples spine surgeries and meniscus repairs in middle age. Some employers are adding digital physical therapy to their MSK portfolio to take a more conservative approach, according to Testa. Others have added his company’s needle-based injection of the patient’s own cells into conditions that would otherwise progress to elective orthopedic surgery. What makes MSK especially challenging is that there often isn’t a single, straightforward treatment pathway, observes John Lawrence, executive director and growth leader for NimbleHealth. “A member with back, knee, hip, shoulder or neck pain may move through primary care, imaging, physical therapy, pain management, orthopedic consultations and ultimately surgery,” he says. Somewhere along the way, he notes, there can be conflicting recommendations, delays in care, difficulty finding the right specialist and uncertainty about whether a more conservative option should be considered first. Much of the innovation in this area centers on intervening earlier in the MSK journey and giving members more support in making treatment decisions, according to Lawrence. That can include helping people understand their diagnosis and treatment options, making it easier to access high-quality in-network specialists, coordinating appointments and promoting appropriate conservative treatments such as physical therapy before progressing to more invasive care when clinically appropriate. He also notes that virtual physical therapy, orthopedic triage and surgical second opinions can help provide timely expert input without unnecessary delays or travel. UNCOMFORTABLE TRUTHS

A guided exercise program prescribed early on will treat the real cause of an MSK condition, restore function and reduce pain – an actual clinical improvement, Khemka says, not pain masked with a pill. Patients who start on physical therapy (PT) to combat low back pain are about 87% less likely to get an opioid prescription, 28% less likely to get imaging and 15% less likely to land in the ER, he explains. The outcomes are tangible. A PT-first path costs about $11,000 a year vs. nearly $37,000 when surgery came first, he says. “But none of that matters if people don’t actually engage,” he adds, noting that the uncomfortable truth about digital-only MSK is that sustained engagement often runs in the low single digits. “You reach the already-motivated, not the high-cost members who need it most.” Another uncomfortable truth is that most self-insured employers manage MSK on the wrong metric, according to Khemka. They stress installs, logins and number of members touched. The problem is that engagement is an input that “never shows up in the claims run the CFO actually pays,” he explains. Self-insured employers that get this right manage MSK on conservative-care-first intervention with real clinician access, claims-based measurement against a matched control group and tie their vendor fees to outcomes, he says.

OCTOBER 2026

MSK's Escape Route Employers underestimate the MSK category for a largely structural reason, explains Andrew White, founder and director of chiropractic for Align & Co. While cancer arrives as a single, unmistakable event that hits the stop-loss report for everyone to see with very little a plan sponsor could have done upstream, he says MSK behaves the opposite way. “It shows up as a hundred quiet interactions that nobody flags: an office visit, an X-ray, a course of anti-inflammatories, a referral,” he notes. “Then 18 months later, the same employee is a fusion, a disability claim and a replacement hire. The spend was never small. It was just distributed.” He cites Sun Life’s 2026 high-cost claims report that ranks orthopedic and MSK conditions as among the most frequent diagnoses in claims exceeding $3 million – a threshold MSK has only recently reached. “Those claims did not appear overnight. They accumulated,” he says. Andrew White

MSK also deserves disproportionate attention because employers pay for it more than once, White notes. For example, a single back injury can show up not only in a group health plan, but also in workers’ comp, short-term disability and the productivity line all at once. The good news for self-insured employers is that MSK is the largest preventable high-cost category. “You cannot screen your way out of a cancer claim. You can absolutely screen your way out of a large share of your spine spend,” according to White. BREAKING SILOS

Sun Life’s 2026 high-cost claims report also noted that MSK conditions repeatedly show up alongside cardiometabolic conditions because they share their underlying risk factors: obesity, diabetes and inflammation. White says an employee with a degenerating knee and A1C creeping in the wrong direction represents a single problem presenting itself in two places. “Treating it with an MSK vendor and separate diabetes vendor, neither of which talks to the other, is a design decision that guarantees you pay twice and fix neither,” he cautioned, which is why his firm built metabolic programming inside rather than beside the MSK front door. The cost of a siloed approach to MSK becomes measurable with popular GLP-1 drugs. Up to 39% of the weight lost on these medications can come from lean mass, which White says is most pronounced in sedentary populations. Muscle loss carries roughly a 60% higher fall risk and substantially elevated disability risk, he explains. “We are systematically reducing muscle in people whose joints are already compromised, and calling it a win because the scale moved,” he warns. “If you are covering GLP-1s without structured strength and movement attached, you are not preventing musculoskeletal cost. You are converting a metabolic claim into an orthopedic one and deferring the bill three to five years, at which point it arrives as falls, fractures and joint replacements.” Khemka has seen a 63% drop in anxiety and depression alongside the pain reduction when a holistic approach is employed. That includes pain-neuroscience education, cognitive behavioral therapy coaching and a warm handoff to behavioral health when it’s beyond the MSK scope. 34

THE SELF-INSURER

MSK's Escape Route “What moves the needle is unglamorous: real human clinical access instead of a chatbot, a way to get people hands-on care when they need it and honest measurement tied to real claims,” he says. The overarching goal is to provide health plan members with better information, access to appropriate clinicians and continued support, Lawrence notes. “One of the biggest lessons is that MSK is not just a provider-network problem or digital-therapy problem. It is fundamentally a navigation and decision-making challenge,” he says. There are more MSK treatment options available today than ever before, he says, but that can create confusion. Members still must figure out where to start, whom they can trust, whether a recommendation is appropriate, how to get an appointment and what to do next if the first treatment does not work, he adds. Lawrence reports meaningful results from more targeted interventions. For example, 59% of members using his company’s virtual orthopedic triage service have avoided an urgent care or emergency room visit. In addition, there has been a 74% decrease in reported pain among members participating in virtual physical therapy and roughly 15% surgical avoidance among members who are considering surgery. MEANINGFUL POINTS OF SERVICE

The cost of an MSK claim largely depends on the point of service. For example, White says a 2022 analysis of nearly 3.8 million commercially insured health plan members with low back pain who started with a chiropractor averaged roughly $5,100 in total downstream cost vs. roughly $9,400 on average for those who started with an orthopedist.

Stronger protection for today’s cost realities As high-cost claims continue to rise, having the right protection matters. Anthem Stop Loss works seamlessly with your ASO medical plan to help manage exposure, reduce complexity, and support more stable financial outcomes. To learn more, contact your Anthem Sales Representative.

Anthem Blue Cross and Blue Shield is an independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

OCTOBER 2026

MSK's Escape Route “The gap is not the office visit. It is everything the office visit sets in motion,” he explains. Advanced imaging was ordered for about 7% of the chiropractic-first group and about 37% of the orthopedic-first group, while back surgery followed in less than 1% of the time vs. about 7% and early opioid prescriptions ran 1.7% vs. 12.6%.

Arpit Khemka

Removing friction for employees helps move the needle on MSK claims. White notes how more than 84% of the workforce at a concrete-industry client of his completed an initial exam and consultation within 30 days when a mobile X-ray unit was brought onsite to do biometrics and MSK/physical exams. “There was no app to download, no appointment to schedule, no PTO to burn, no drive across town,” he reports.

More than half of those employees had unaddressed injuries that had been mounting for months or years, while nearly a quarter were classified as high risk. That meant they were on a trajectory toward imaging, specialist referral or surgery if nothing changed. Based on historical claims patterns, he says that the high-risk group alone represented more than $800,000 in future liability. “By intervening early and redirecting care before escalation, that exposure was largely eliminated,” White says, adding that the employer’s investment produced about a tenfold reduction in downstream MSK risk. When employees delay MSK care, White says it’s not because they’re unmotivated. The issue is that they’re responding to a system that makes early action expensive and inconvenient and late action automatic. “Fix the friction, and you do not need the motivation,” he adds. His suggestion is that employers shorten the time between onset and first contact for MSK. Pain that gets addressed in the first week is a movement problem, he explains, while the same pain in month eight is a neurological, behavioral and psychosocial problem that will cost 10 times as much to treat. “The clinical difference between those two patients is mostly just elapsed time,” he says. POWER OF PARTNERSHIPS

Testa has seen the downstream effect of an unhealthy workplace during more than 30 years in the work comp space, which is why he says it’s critical to match the right person with the right job. “If you can’t find the right person, spend time either training them to do the job without injury or helping them become tactical athletes for that job,” he suggests. Occupational medicine lags behind the innovation that self-funded employers and cash-pay patients already have access to, which Testa says is platelet-rich plasma injections for MSK conditions. “Adding innovations like that reduces impairment ratings, keeps people from surgery and gets them back to work quickly,” he says.

THE SELF-INSURER

Mark Testa

Interstellar National Conference Party | October 13, 2026 JW Marriott Desert Ridge | Ballroom Lawn | 7:30p - 10p

ALL SYSTEMS ®

THIS is where the business of self-insurance gets done.

MSK's Escape Route In the end, there’s no denying the power of partnership. “Many employers are pushing solution providers like us to find ways to work together,” Testa reports. “As more employers become sophisticated enough to understand there’s no single fix for lowering healthcare costs, holistic and interconnected solutions need to focus on a number of areas. They include smart communication strategies, a quality patient experience, easy hand-offs for referrals and working within the ecosystem the employer has already built in order to save money.”

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

Amalgamated Life Insurance Company Medical Stop Loss Insurance— The Essential, Excess Insurance As a direct writer of Stop Loss Insurance, we have the Expertise, Resources and Contract Flexibility to meet your Organization’s Stop Loss needs. Amalgamated Life offers:

• Specialty Rx Savings Programs and Discounts

• Excellent Claims Management Performance

• “A” (Excellent) Rating from A.M. Best Company for 48 Consecutive Years

• Specific and Aggregate Stop Loss Options

• Licensed in all 50 States and the District of Columbia

• Participating, Rate Cap and NNL Contract Terms Available

• Flexible Contract Terms

VO LU NTARY SOL UTION S—KEEPIN G PACE WITH TOD AY ’ S NEEDS

• Accident

• AD&D

• Critical Illness

• Dental

• Disability

• Hearing

• ID Theft

• Legal

• Portable Term Life

Amalgamated Life Insurance Company 333 Westchester Avenue, White Plains, NY 10604 914.367.5000 • 866.975.4089

• Whole Life Insurance

For product information, contact: marketing@amalgamatedbenefits.com

www.amalgamatedbenefits.com

Group • Stop Loss • Voluntary

Policy Form ALSLP-2020* *Features & form numbers may vary by state.

A M A L G A M AT E D F A M I LY O F C O M PA N I E S

THE SELF-INSURER

| Amalgamated Life | Amalgamated Employee Benefits Administrators | Amalgamated Agency | AliGraphics

A M

BES S ST T

A Strategic Advantage for Benefits Consultants and TPAs Mayo Clinic Complex Care Program

55%

of patients experience a change in diagnosis

Mayo Clinic’s Complex Care Program is a customizable center of excellence solution designed to integrate seamlessly with your existing offerings. Whether you’re advising self-funded employers or evaluating their COE networks, our program helps you deliver measurable value. We’ll work through your preferred pathways or build new ones together. Let’s make complex care simple, strategic, and impactful. All without added fees. Learn more: mayoclinic.org/complex-care-program © 2025 Mayo Clinic

82% see a change in treatment plan

AI THAT CAN BE CROSS-EXAMINED: BUILDING TRUSTWORTHY CLAIM DECISIONS IN THE SELF-INSURED MARKET Why the next generation of health plan AI must move beyond black-box prediction and toward auditable, deterministic reasoning.

Written By Ashish Jaiman

elf-insured employers and alternative-risk-transfer leaders are being asked to make a difficult leap. They must manage rising healthcare costs, protect plan assets, preserve member access, maintain provider relationships, support stop-loss and captive partners and respond to a regulatory environment that increasingly expects documentation, oversight and discipline. At the same time, artificial intelligence is arriving with promises that sound almost too convenient: faster reviews, better predictions, automated summaries, smarter prior authorization, stronger fraud detection and instant insight from documents that previously took experts hours to interpret. The opportunity is real, but the industry should be careful about the unit of trust. In a consumer setting, a useful AI response may be enough. In a self-insured health plan, a useful response is not enough. A payment-impacting decision must be explainable to a plan fiduciary, defensible to a provider, understandable to a TPA, useful to a broker or consultant, and reproducible under audit. The right question is no longer simply, “Can AI find more savings?” The better question is, “Can AI show the exact basis for the decision and prove that the same facts would lead to the same outcome tomorrow?” That distinction matters. The self-insured market does not need AI as a mystery box. It needs AI that can be cross-examined. 40

THE SELF-INSURER

PREDICTION IS NOT THE SAME AS PROOF

Many health plan AI initiatives start with prediction. A model assigns a claim a risk score. A dashboard identifies an outlier. A system detects a pattern that resembles waste, abuse, or billing error. These capabilities can be helpful, especially when the alternative is manual review of enormous claim volumes. But prediction alone does not solve the hardest part of payment integrity. It does not explain whether the plan document allows a specific benefit. It does not establish whether a reimbursement term applies to a particular provider on the date of service. It does not determine whether clinical documentation satisfies a medical policy. It does not tell a fiduciary whether a proposed action is consistent with the plan’s terms and the interests of participants and beneficiaries. A probabilistic model can say that something looks unusual. A defensible claim decision must say why action is appropriate. That “why” has to connect multiple forms of evidence: the plan document, summary plan description, provider contract, medical policy, coding guideline, fee schedule, clinical record, stop-loss provision, network status, eligibility data, prior authorizations, and the claim itself. In practice, the answer is rarely found in a single system or document. It is assembled from fragments. This is where a purely black-box approach becomes fragile. If a model cannot identify the source language, version, effective date, and reasoning path behind its conclusion, then the plan may have an interesting signal but not an operational decision. Signal without evidence creates work. Evidence with reasoning creates governance. WHAT GLASS-BOX AI MEANS FOR SELF-INSURED PLANS

A more useful model for the self-insured market is glass-box AI. The term does not mean that every mathematical detail must be digestible to every stakeholder. It means that the decision process is observable, testable, and governed. A glass-box system should be able to answer basic executive questions without hiding behind the phrase “the model said so.” What source documents did the system use? Which plan or policy provisions were applied? Were the provisions effective on the date of service? What clinical facts were extracted, and from where? What was uncertain? Which rules were deterministic, and which steps involved probabilistic interpretation? Was a human reviewer required? What alternative outcomes were considered? What changed from the prior version of the rule? Was the same rule applied consistently across similar cases? For self-insured plans, these are not academic questions. ERISA-covered group health plans operate in a fiduciary context. Plan decision-makers are expected to act prudently, follow plan terms when those terms are consistent with applicable law, pay only reasonable plan expenses, and serve participants and beneficiaries. AI does not eliminate those obligations. It changes the evidence base that fiduciaries and their delegates may use to carry them out. This creates a practical standard: AI used in claim administration and payment integrity should produce a reasoning trail that a fiduciary committee, TPA, stop-loss carrier, broker, consultant, provider, or auditor can review. The most valuable output is not a score. It is an evidence packet. THE NEURO-SYMBOLIC ARCHITECTURE: READING PLUS REASONING

The technical direction most suited to this problem is often described as neuro-symbolic AI. The phrase sounds complex, but the business idea is straightforward. The “neural” layer is useful for reading and OCTOBER 2026

interpreting messy information. Modern language models can extract relevant facts from clinical notes, summarize contracts, compare policy language, normalize terminology, and identify ambiguities across large document sets. That is a major breakthrough because health plan knowledge is scattered across PDFs, amendments, emails, portals, claim systems and third-party data feeds. The “symbolic” layer is different. It represents rules, relationships and constraints in a form that can be inspected and executed. A symbolic layer can encode plan provisions, reimbursement rules, modifier logic, code relationships, medical-necessity criteria, contract hierarchy, exclusion language, effective dates and escalation thresholds. It can also use knowledge graphs to connect entities that are frequently separated across systems: member, employer group, provider, facility, network, procedure code, diagnosis, drug, policy, contract, episode of care and payment rule. The combination matters because health plan decisions require both reading and reasoning. A language model may read a clinical note and identify that a member had a specific diagnosis, procedure, or treatment history. But the final payment recommendation should not rest on language-model intuition alone. It should be evaluated against deterministic rules that encode the plan’s actual terms and policies. In other words, AI can help understand the facts, but the rules must still decide what those facts mean for the plan. This is why determinism is not the enemy of innovation. In payment-impacting workflows, determinism is the control layer that makes AI usable. The same facts, plan terms, contract version, and rule set should lead to the same result. When they do not, the system should be able to explain why: perhaps a policy changed, an amendment took effect, a provider moved networks, a threshold was exceeded, or the clinical record introduced new evidence.

THE SELF-INSURER

Rethink what’s possible with your stop-loss partner For over 40 years, Sun Life has partnered with self-funded employers to help manage risk. Today, we’re continuing to evolve, connecting stop-loss protection with programs designed to help employees access appropriate care for complex and high-cost conditions.

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

Learn more about our offerings by scanning:

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

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

A HIGH-COST CLAIM EXAMPLE

Consider a high-cost facility claim. A predictive model might flag it because the allowed amount is higher than peers, the diagnosis-related group appears unusual, or the charge pattern resembles past overpayments. That is a useful starting point, but it is not enough for action. A glass-box approach would assemble the claim’s decision record. It would identify the member’s eligibility and plan version on the date of service. It would map the billed codes to the relevant reimbursement rules. It would compare the provider’s network and contract status against the claim line. It would locate any medical policy criteria that apply to the service. It would read the clinical documentation for facts needed to satisfy or fail those criteria. It would check whether any prior authorization, carveout, stop-loss notice requirement, exclusion, coordination-of-benefits rule, or plan amendment changes the analysis. It would calculate the expected reimbursement and show the basis for any variance. The resulting output should be plain enough for an executive to understand and detailed enough for an expert to validate. It might state: the claim is payable, but should be repriced under a specific contract clause; or the claim requires additional documentation because the medical policy criteria were not supported in the record; or the claim should be escalated because stop-loss notice timing, diagnosis complexity or potential experimental-treatment language creates risk; or the claim should be paid because the apparent anomaly is explained by a valid contract provision and the clinical record supports the service. In each case, the key is not whether the system is aggressive or conservative. The key is whether the system is grounded. A grounded decision shows the documents, facts, rules, calculations, and unresolved questions that led to the recommendation. HUMAN OVERSIGHT SHOULD BECOME SHARPER, NOT HEAVIER

A common misconception is that responsible AI necessarily adds more manual review. It can, if implemented poorly. But the better objective is sharper human oversight. Experts should not spend their time searching for the same clause, re-reading the same medical record, or manually copying data from one system to another. They should spend time on judgment: ambiguous provisions, novel clinical scenarios, high-dollar exceptions, provider disputes, regulatory exposure, and cases where plan values or member experience require careful interpretation. Human-in-the-loop design should therefore be risk-based. Low-risk, rule-clear cases may be processed with automated evidence generation and sampling. Moderate-risk cases may require expert review of the evidence packet. High-risk cases should trigger escalation to the appropriate clinical, legal, fiduciary, stoploss, or executive stakeholders. The point is not to replace judgment. The point is to reserve judgment for the cases that deserve it. This also changes how organizations should evaluate AI vendors and internal AI projects. Accuracy matters, but it is not enough. Leaders should ask for reproducibility, source traceability, version control, exception handling, reviewer overrides, audit logs, security controls, validation methodology, and post-deployment monitoring. They should ask how the system separates probabilistic extraction from deterministic decision rules. They should ask whether a claim decision can be reconstructed six months later, after the policy library, contract set or model version has changed. THE GOVERNANCE CHECKLIST

Before trusting AI in payment integrity or claim administration, self-insured stakeholders should consider a simple governance checklist. 44

THE SELF-INSURER

Today’s stop-loss market demands more than rigid structures that offer stock solutions.

Confidence to Think Creatively F E D E R A L L I F E I N S U R A N C E C O M PA N Y

At Federal Life Insurance Company, entrepreneurial thinking is driven by institutional experience, creative solutions are executed with discipline, and flexibility comes from reliability. Working with program administrators, TPAs, MGUs, brokers and intermediaries, our partnership-driven approach is built for program business today.

Fronting, Captives & Selective Risk Participation Structured for flexible program design. Easy to Work With Responsive, collaborative, and structured to keep programs moving.

125+ Years of Insurance Experience Disciplined execution backed by long-term stability. Stop-Loss–Led A&H Program Business Supporting modern group benefit strategies.

www.FederalLife.com •

Federal Life Insurance Company

For agent/producer purposes only – not for solicitation to consumers. Product availability varies by state and is subject to change. This material is intended for informational purposes only and does not constitute an offer of insurance. All insurance products are subject to underwriting approval and applicable regulatory requirements. Product terms, conditions, and availability may vary by jurisdiction. © 2026 Federal Life Insurance Company. All rights reserved. FLIC-SIIAAD-052726

First, data lineage: can the system show where each fact came from? This is especially important when working with clinical notes, plan amendments, provider contracts, and transparency data. Second, rule authority: can the system identify which provision or policy gives it the authority to recommend an action? A finding that lacks plan authority may create abrasion without improving governance. Third, version awareness: does the system know which plan document, contract, policy, or fee schedule was effective on the date of service? Fourth, determinism: when a rule is intended to be deterministic, does it execute the same way every time under the same facts? If randomness or model variability is involved, where is it allowed and how is it controlled? Fifth, escalation: when the evidence is incomplete, ambiguous, or conflicting, does the system stop and escalate, or does it force a confident answer? Sixth, auditability: can the organization reconstruct the decision after the fact, including the source documents, rule versions, reviewer actions, and final rationale?

Expertise,

Not Just Execution. Placing a self-funded plan takes execution. Managing one well takes expertise. CRC's Self-Funded Division brings actuarial, clinical, and claims expertise to operate as a genuine co-pilot on the account, not a back-office vendor. Advisors don't need a partner who places the business. They need one who helps win it.

THE SELF-INSURER

Seventh, security and privacy: because health and welfare plans can hold sensitive participant data, AI systems must be evaluated with the same seriousness applied to other plan data environments. Responsible AI governance and cybersecurity governance should not be separate conversations. These questions are not barriers to innovation. They are the conditions that allow innovation to scale safely. FROM REACTIVE SAVINGS TO PREVENTIVE GOVERNANCE

The most significant opportunity is not faster post-payment recovery. It is prevention. When claim findings are converted into executable rules, plans can reduce repeated errors before they compound. When contract provisions become computable, reimbursement disputes can be identified earlier. When medical policies are connected to clinical documentation, review teams can focus on evidence gaps instead of manual discovery. When transparency data is integrated with claims and contracts, employers and advisors can make better purchasing and network decisions. For stop-loss carriers and captive partners, better evidence can improve communication around high-cost claims, lasers, exclusions, notices, and reimbursements. For TPAs, it can reduce rework and support more consistent administration. For brokers and consultants, it can

Everything You Need to

Navigate the 2026 Benefits Landscape With the benefits market more complex than ever, brokers and their clients deserve better tools to navigate it. This comprehensive annual market report spans across the full spectrum of the benefits market providing actionable insights and data to you and your clients. Inside, you’ll find expert analysis on: – Economic & Regulatory Conditions – Market Trends & Insights – Carrier Insights – Technology & AI – Benchmarking Data – Best Practices & Strategic Renewal Approaches

Take a deeper dive into these insights and more in the full report. Available NOW!

Small to Mid-Market

Self-Funded

Ancillary

Exclusive Programs

Retiree Healthcare

create a clearer basis for plan recommendations and vendor evaluation. For employers, it can strengthen fiduciary documentation and help ensure that plan assets are used according to plan terms. For members and providers, it can reduce frustration stemming from unexplained denials, inconsistent decisions, and opaque payment logic. The goal is not to turn every health plan into a software company. The goal is to make the plan’s intent computable. A self-insured plan is already a rules engine in legal form. It defines eligibility, benefits, exclusions, reimbursement obligations, and administrative processes. AI becomes powerful when it helps convert that legal and operational intent into consistent, explainable execution. THE FUTURE STANDARD: AI THAT CAN DEFEND ITS ANSWER

The next few years will likely separate two kinds of health plan AI. One kind will generate impressive summaries, alerts and scores but struggle to support payment-impacting decisions. The other kind will connect prediction to proof. It will read complex documents, extract evidence, apply deterministic rules, escalate uncertainty, and create a record for human inspection. Self-insured executives should favor the second path. In this market, trust is not created by automation alone. Trust is created when a system can state what it knows, show where it learned it, apply the correct rule, acknowledge what remains uncertain, and preserve the record for review. The future of AI in self-insurance will not be defined by the most dramatic demo. It will be defined by the decision that can be defended when challenged. Prediction may identify the opportunity. Proof will determine whether the opportunity can be acted on. For self-insured plans, the winning AI will not be the one that sounds most confident. It will be the one that can be cross-examined.

Ashish Jaiman is a healthcare AI entrepreneur and former enterprise technology product and engineering leader. His work focuses on trustworthy AI, neuro-symbolic systems, deterministic reasoning, Graph-RAG, policy-as-code, and human-in-the-loop governance for regulated healthcare finance workflows. He writes and speaks about moving healthcare AI beyond black-box prediction toward auditable, evidence-backed reasoning systems that employers, TPAs, payers, brokers, stop-loss partners, and fiduciaries can trust.

PROTECT YOUR PLAN WITH PROVEN COST CONTAINMENT SOLUTIONS Overbilling and inflated medical costs threaten your plan’s financial stability. H.H.C. Group delivers comprehensive cost containment solutions that safeguard your bottom line — from attorney-led negotiations and bill reviews to reference based pricing and DRG validation. With 30 years of experience and industry-best turnaround times, we help self-funded employers achieve savings of up to 90% on high-cost claims, protect fiduciary responsibility and ensure fair, defensible payments.

Real People. Real Savings.

301.960.7092 | sales@HHCGroup.com

THE SELF-INSURER

SEE HOW H.H.C. GROUP’S FULL SUITE OF COST CONTAINMENT SERVICES

PROTECTS YOUR PLAN.

Forward. Upward. Onward.

Pinnacle Claims Management, inc. is now Pinnacle Health Solutions. For more than 30 years, we’ve partnered with self-funded employers to simplify health benefits through responsive service, expert claims administration, and personalized health management. Today, we’re bringing everything together under one name: Pinnacle Health Solutions. Our new brand reflects the breadth of solutions we deliver and the integrated experience we’ve built for brokers, employers, and members. Same trusted team. Same exceptional service. One unified identity.

pinnacle-health.com

THE DIGITAL HEALTH DILEMMA: WHAT’S WORKING AT WHAT COST?

Written By Laura Carabello

ith a whopping 28.4 million Americans expected to wear Apple Watches in 2026 and another 2.5-2.8 million using an Oura Ring, it’s likely that many employees will be sporting these devices in the workplace. Over 26% of Americans own a smartwatch device, including around 81 million Americans using various fitness trackers, with smartwatches leading the category. Aspirational Artificial Intelligence (AI) proponents point to the potential for smartwatches to monitor emotional changes and detect early anxiety and depression. Mayo Clinic scientists believe answers to improving mental well-being “might already be on your wrist.” Interestingly, Health and Human Services Secretary Robert F. Kennedy Jr. has suggested every American could use a wearable device to track their health metrics and said HHS would launch a marketing campaign to promote them as a key to preventative health. However, the Medical Device and Diagnostic Industry warns that while consumer wearables promise empowerment, they may be creating anxious patients who over-monitor. They ask the question: “Are we tracking health or fueling health anxiety?” This upsurge in adoption is reflected in U.S. digital health venture funding, which reached $7.4 billion across 244 deals in the first half of 2026. Largely fueled by investor interest in mental health, weight management and artificial intelligence (AI), a survey published by the venture capital firm and consultancy

THE SELF-INSURER

Rock Health shows that overall, 19 digital health companies secured 20 mega deals, representing 45% of all capital invested in the first half of the year compared with 42% in the year-ago period. Investors anticipating significant profits are buoyed by consumer demand for wearables. Today, the American appetite mirrors international trends as US residents increasingly turn to these connected devices to manage their health and share data with providers. Rock Health also reports that nearly 60% of U.S. adults reported owning at least one wearable or connected device, like continuous glucose monitors, smart scales or connected blood pressure cuffs. As data from these devices becomes integrated into the traditional healthcare system, providers are potentially enabled to see a long-term view of their patients’ health. Surveyors report that nearly 60% of wearable owners have already discussed their data with a provider, including 30% who said they do so regularly. Researchers document that wearables are primarily used to track physical activity, sleep and heart rate, and 59% of respondents reported wearing their devices always or almost always – including at work. From an employer perspective, it’s likely that employee owners of connected devices and wearables tend to be younger, wealthier, healthier, more urban and more likely to be commercially insured, although just 12% received a device through their insurer or employer. The VCA Software narrative indicates that the insurance industry is undergoing a technology transformation unlike anything seen in the last century. U.S. insurance technology budgets are projected to reach $173 billion in 2026, growing 7.8% year over year, representing 6% of total U.S. technology spending. MEASURABLE SAVINGS & ACCOUNTABILITY

“Digital point solutions can create savings, but the savings are not created by the application itself,” says Dea Belazi, PharmD, MPH, CEO & cofounder, AscellaHealth LLC. “They are initiated by the clinical action the application enables, and the costly event that action prevents, making savings expectations highly dependent on the condition and related form of care.” Belazi explains that in the case of virtual musculoskeletal care, for example, “The Peterson Health Technology Institute’s assessment found that physical therapist-guided virtual programs can deliver outcomes comparable to in-

Dea Belazi OCTOBER 2026

person physical therapy. The study estimated $4.4 million in annual savings per one million commercially insured members when eligible low-back-pain patients shifted to appropriately priced virtual care as a replacement for in-person care.” In contrast, Belazi points out a review of digital programs for asthma and COPD which showed results that did not always generate enough medical savings to offset their costs, with results that varied significantly based on the population, intervention and delivery model. “One of the greatest opportunities to get value from a digital point solution is by strategically targeting high-cost, low-volume claims, like medical benefit specialty pharmacy care,” he continues. “The opportunity is particularly significant because the patient population is smaller, the clinical complexity is higher, and even incremental improvements in coordination and benefit management can have a meaningful impact on total cost of care and member experience.” From a technology perspective, effective digital solutions need to address system interoperability and connect fragmented processes, not just to help employers better manage complex care journeys but to bring together the data needed to monitor and assess program effectiveness. “By enabling greater visibility into utilization, prior authorization workflows, specialty pharmacy pathways, financial support options and site-of-care decisions, technology can help identify opportunities to improve outcomes while reducing unnecessary costs,” Belazi concludes.

Vincent Esposito

Vincent Esposito, CEO, Reflect Health, not only sees the rise in solutions by disease state, but also the rise of services that measure the efficacy of vendor services to drive accountability beyond marketing and measuring real ROI/results.

“We also see more stop-loss carriers willing to give rate relief for high-performing vendors,” says Espositio. “Within disease states, we see folks tackling MSK, oncology, dialysis, diabetes, infusions, etc. The list is growing rapidly. “ Employers can flatten the cost curve for their most expensive employee chronic populations by starting directionally, navigating and optimizing the use of a health plan. “In theory, you get cost impact, but the value it really brings is the assistance it provides in where to seek care next,” he adds. “Directionally, the ability to avoid a trip to the ER for a higher value option impacts cost most meaningfully.” IMPACT OF AI

AI is an important component of medical device development, which analysts contend is lowering the barriers to building single-use-case digital solutions. AI transforms digital health devices by shifting healthcare from reactive treatments to proactive prevention. Scientists tout AI as a key enabler of continuous monitoring of chronic conditions, allowing devices to interpret vital signs instantly and help predict medical events before they happen: Remote Patient Monitoring (RPM): Wearable sensors use machine learning to filter movement noise and track irregular heartbeats or blood oxygen levels. Personalized Insights: AI analyzes lifestyle, genetic, and biometric data to create custom health plans for users. 52

THE SELF-INSURER

Workflow Automation: AI agents in devices automatically summarize data and send alerts to doctors. Technology-Driven Solutions Transform Wellness to Wellbeing Many self-insured companies have started exploring technological solutions to improve employee health and well-being, facilitating the transition from wellness to well-being. Truworth Wellness points to these benefits: 1. 24/7 Accessibility: Health and well-being software solutions typically provide a single login that allows access to all employee information from anywhere and at any time. This enables HR to assign health tasks according to their convenience and availability and track the status of these tasks. 2. Empowers People: Health benefits software solutions empower employees by granting them access

to well-being programs, health check plans, and services regardless of the device they use. This eliminates the dependency between HR and employees when it comes to well-being activities such as understanding wellness plans, checking healthcare claims and purchasing health check solutions.

3. Workflow Automation: Health benefits solutions have introduced automated work environments

in workplaces, providing convenience for HR professionals. HR personnel can now focus on new projects and tasks to increase productivity.

4. Enhanced Decision-Making Skills: Technology-driven health and well-being solutions have

enhanced the decision-making skills of HR professionals. They create a centralized system to store employees' health data, enabling HR to make informed decisions about employee health check plans and well-being programs. HR can easily determine if the existing wellness program is positively impacting the company in terms of improved health and productivity. Based on insights captured in the software, HR can suggest improvements and identify areas for employee well-being.

5. Boost In Telemedicine: During the pandemic, employees with chronic health conditions faced

challenges in seeking proper medical advice and support while managing their workload. Thanks to telemedicine, a technology-backed service, employees can access medical assistance outside of working hours. This way, they can remain at home without missing work hours or experiencing unnecessary stress.

THE SELF-INSURER

Jim Carlson, VP, Evidium, head of business development, selffunded, notes, “The real value isn’t simply knowing where a patient’s care journey is headed—it’s understanding why they are going down that pathway and having the insight to intervene before they reach costly or unnecessary treatment. By looking at the entire healthcare journey—not isolated treatments, conditions, or comorbidities—we can create more precise care pathways that improve both the patient experience and clinical outcomes.” He says there are many solutions in the market, but not every solution is designed to meet an organization’s unique needs. “The advantage of a solution like Evidium is the ability to customize the platform around those specific needs, rather than forcing the organization into a one-size-fitsall approach,” adds Carlson. “With earlier insight into a patient’s clinical trajectory, we have an opportunity to guide care more effectively and improve delivery. Clinical and financial outcomes are not competing priorities. When we improve the clinical outcome, the financial outcome inherently improves as well.” PHYSICIAN UNCERTAINTY

A study by the American Medical Association found only 6% of U.S. physicians regularly use consumer wearable data in patient care. The trade group’s study defined consumer digital wearables as nonprescription, commercially marketed technologies used by individuals to monitor personal health, fitness and performance. It did not include prescription medical devices such as continuous glucose monitors and clinical diagnostic tools such as mobile cardiac telemetry or home sleep apnea tests. More physicians are looking to incorporate patients’ consumer wearables, such as smartwatches and fitness trackers, into their care, but barriers to wider usage remain. A key obstacle to wider adoption is missing reimbursement pathways, as CPT remote monitoring codes don't cover consumer wearables. OCTOBER 2026

While there appears to be strong physician interest, just 18% of physicians expect consumer wearable data to be more widely used in a clinical setting within the next year. Increased interest varies across specialties. Some cardiologists and endocrinologists already review data from the devices and are more optimistic about potential care benefits. Other physicians, such as those working in primary care, are more hesitant to add wearable devices to the mix. IMPACT ON BEHAVIORAL HEALTH

From a behavioral health perspective, Dani Kimlinger, PhD, MHA, SPHR, SHRM-SCP, CEO, Mines and Associates explains, “Digital health solutions can create meaningful value for self-insured employers when they improve access, engagement, and early intervention. We have seen strong results when digital tools are integrated into a broader continuum of care rather than deployed as standalone point solutions.” For example, she says employees may begin with a digital mental health screening and then be seamlessly connected to counseling, coaching, care Dani Kimlinger navigation, or work-life services when additional support is needed. Similarly, employees managing chronic conditions often benefit when digital monitoring, health coaching, behavioral health support, and primary care are coordinated rather than fragmented. “While many digital solutions demonstrate positive outcomes, employers are increasingly facing point solution fatigue as multiple apps compete for attention,” says Kimlinger. “Utilization and ROI suffer when employees are unsure where to turn. The future is not simply more digital health tools, but integrated ecosystems that combine physical health, behavioral health, navigation, and human support into a trusted, streamlined experience that improves outcomes while reducing complexity.” There’s widespread industry support for the value of digital health point solutions to improve access, engagement and outcomes. April Gill, CCO, Smart Data Solutions, says the challenge is what happens as they multiply. “For TPAs and self-insured employers, every new solution can introduce another data feed workflow, login, integration and reporting requirement,” she advises. “The result can be a fragmented experience for members and growing complexity behind the scenes. The answer is not simply replacing every point solution with one platform. It is building an operational foundation that connects the ecosystem.”

April Gill

As employers demand greater value and interoperability improves, Gill says the winners will be solutions that work as part of a connected ecosystem. The future of digital health isn’t more apps -- it is making the right solutions work together at scale. INTEGRATION OF AI IN DIGITAL MENTAL HEALTH

As validated by the Substance Abuse and Mental Health Services Administration (SAMHSA), more than 1 in 5 U.S. adults experience mental illness each year, posing accelerated demand for accessible and affordable solutions. Access to mental health clinicians has been limited by cost, availability, geography or stigma, leaving AI tools and mobile applications as a scalable and reliable response to this challenge that is positioned to close some of these gaps. 56

THE SELF-INSURER

Mental health apps work by offering evidence-based techniques such as cognitive behavioral therapy (CBT), meditation, or mindfulness exercises. Covington Digital Health explains that they help users track moods, manage stress and build healthy habits through daily reminders and interactive activities. Some apps use AI-driven chatbots to provide emotional support, while others connect users to licensed therapists for online consultations. However, their rapid adoption has raised questions about safety, accuracy, legal responsibilities and the protections available to consumers.

Source: 2026 National Alliance on Mental Illness Market trackers report that these on-demand solutions are particularly appealing to younger generations and cost-sensitive populations. Market.US contends that the democratization of mental health support is positioning apps as essential tools in preventive care and self-management strategies. Industry predictions on the use of AI apps for mental health follow a consistent theme, as articulated by Spring Health: “In 2026, employees will increasingly use general-purpose AI tools for mental health support, which will create serious risks around privacy, confidentiality and misuse.” This matters because employees are increasingly experimenting with general-purpose AI for emotional support, with a focus on text generation, not safety. But they are not substitutes for diagnosis, crisis response or clinician judgment.

OCTOBER 2026

These apps include ChatGPT, Character.AI or casual wellness bots that do not guarantee legal medical privacy. They can actually log conversations to train future AI models. Furthermore, they lack human oversight and may provide bad advice, miss signs of crisis or create fake information, such as hallucinations. Unfortunately, they follow no rules and are essentially unregulated wellness bots, not medical devices. Conversely, mental health companies that utilize AI apps with professional, medical-grade digital therapy employ licensed, human professionals backing the technology. Trends highlighted by the APA Monitor show that AI is not a distant future but a current reality that clinicians must engage with to stay competitive and effective in their practice. Intelligent healthcare applications intended for medical purposes often qualify as medical devices under FDA regulations as described earlier. It will be incumbent upon plan sponsors to separate consumer AI tools from mental health companies that were built for clinical trust, privacy and continuity. Employers that contract with reliable, trusted behavioral health platforms are ensured clinical accuracy, strict legal privacy protections, such as HIPAA, and steady, long-term care. They follow strict healthcare privacy laws to keep medical data secure, featuring built-in warning systems to alert human clinicians if the individual is in danger or crisis. They also adhere to rigorous medical and ethical standards established by governing bodies. When it comes to a behavioral health journey, one digital solution is resolving the challenges of connecting members to the appropriate clinician. As an example, TPN.health provides an integrated ecosystem that fixes these issues. “With our solution, the employer has just one contract and one entity accountable for the whole member journey,” says Trevor Colhoun, CEO and co-founder, TPN.Health. “A member texts to start care, without sorting through an outdated directory, a licensed Care Navigator gets them to the right care and credentialing and claims are handled in-house. No directory, just one NPI, one tax ID – all on one dashboard. This translates into a reduced number of unnecessary appointments, better and significant cost savings for the health plan.”

Trevor Colhoun

Colhoun attests that this model fixed the provider economics: first by offering fast credentialing and competitive rates within 30 days in addition to free continuing education.

“This creates a living network with actual depth,” he continues. “Depth is what produces a clinical match, and a match is what produces continuity. Everything the employer cares about, including cost, follows from that." PEOPLE ARE HESITANT TO USE MENTAL HEALTH AI

While research suggests individuals may be open to AI tools in therapy, the extent of that comfort level is limited. A national survey by YouGov found that Americans remain hesitant to use AI for mental healthcare, with only about 11% say they would be open to using it, and just 8% say they trust it. Nearly half of respondents said they are reluctant to use the technology. Many point to the lack of human understanding as a major concern, along with fears about inaccurate advice and privacy. 58

THE SELF-INSURER

A separate survey from the health research organization KFF found that about 77% of Americans are worried about how their health information would be stored and used by AI systems. ARE AI AND MACHINE LEARNING (ML) MEDICAL DEVICES REALLY SAFE?

Along with its responsibilities for examining clinical data, manufacturing processes and product labels to ensure human and animal products are safe and effective, the Food and Drug Administration(FDA) reviews medical devices through an appropriate premarket pathway, such as premarket clearance (510(k)), De Novo classification, or premarket approval. The FDA may also review and clear modifications to medical devices, including software as a medical device, depending on the significance or risk posed to patients of that modification. After publishing multiple discussion papers from 2019 through 2024, in 2025 the FDA published draft guidance proposing both lifecycle considerations and specific recommendations to support marketing submissions for AI-enabled medical devices.

OCTOBER 2026

Further ensuring safety, the FDA has established the Digital Health Center of Excellence (DHCoE), a specialized division within the Center for Devices and Radiological Health with a goal to provide regulatory oversight and advance safety for software as a medical device, artificial intelligence and wearables. The DHCoE sets policies for AI and ML in healthcare, establishes medical device cybersecurity standards, adjusts oversight on low-risk consumer wellness products and manages pilots or other programs. Despite these advancements, challenges remain, including the risk of biased algorithms and data privacy concerns. In response, the regulatory bodies continue to issue safety guidance to address these risks.

Source: 2026 Digital Health Center of Excellence GET FAMILIAR WITH TEMPO AND ACCESS

Before engaging a vendor, benefits decision-makers should familiarize themselves with recently introduced FDA programs regarding the use and safety of digital medical devices. TEMPO There’s a brand-new program this year from the FDA: Technology-Enabled Meaningful Patient Outcomes (TEMPO) for Digital Health Devices Pilot, a voluntary pilot designed to promote access to certain digital health devices while safeguarding patient safety. It allows limited, clinician-supervised use of certain digital health devices for chronic disease management, with active performance monitoring. Devices included in the pilot may be intended for low-acuity cardiometabolic conditions such as prediabetes, musculoskeletal issues such as back strain and behavioral health conditions such as depression.

THE SELF-INSURER

TEMPO is run by FDA's device center in connection with a CMS payment model (ACCESS) and is just getting underway. In late July, the FDA selected Dexcom as the first participant in the digital health pilot. ACCESS ACCESS is a 10-year national payment model under the Center for Medicare and Medicaid Innovation that was scheduled to begin on July 5, 2026 and run through June 30, 2036. ACCESS introduces outcomealigned payments (OAPs) that are intended to provide predictable, recurring payments to participating organizations for managing patients with qualifying chronic conditions. TEMPO and ACCESS Together Together, TEMPO and ACCESS are intended to provide regulatory flexibility and value-based payment, with the goal of accelerating adoption of and evidence generation for digital health medical devices. The important limitation is that devices offered under TEMPO may not be marketed for the same intended use outside of ACCESS while relying on TEMPO enforcement discretion. Practically speaking in terms of employer benefits, TEMPO is a weaker signal than FDA clearance, not a stronger one. If a vendor markets a device as being "part of an FDA program" to imply safety validation, it may be worth pushing back since TEMPO devices are explicitly pre-authorization. DEFINING THE VALUE PROPOSITION FOR EMPLOYERS

Self-insured employers largely believe digital health tools reduce costs and improve health outcomes. As 2027 is now on track for significant increases in the medical cost trend – the highest in nearly two decades with expectations that it will rise to 9% -- companies now view these tools as critical for better care management: •

Lower Costs: Virtual care avoids expensive emergency room visits and controls chronic illnesses like diabetes.

•

Improve Outcomes: Members gain on-demand access to health coaches, nutritionists, and mental health support.

•

Track Data: Self-funding gives employers the claims data to independently verify if a tool actually works. However, managing too many separate apps is creating vendor fatigue. For many employers, vendor “overload” is creating both operational and administrative costs that potentially rival the savings that these programs are meant to provide.

Rajiv Sood

Rajiv Sood, general manager, Insurance & Risk, Evidium, Inc., states, "While there is already no shortage of point solutions/devices -- with more coming to market all the time, digital health solutions in general, have the greatest potential to create measurable value when they help employers address their most complex and costly conditions. With a small percentage of the population driving most of the costs, early identification, evidence-based care pathways and proactive management can significantly impact outcomes and total cost of care.” OCTOBER 2026

He says the challenge for self-insured employers is less about whether digital solutions can deliver value, but more about how to determine which programs are truly improving outcomes while navigating a growing ecosystem of disconnected vendors and data sources. “By providing clinically grounded, explainable healthcare predictions, our predictive clinical disease state, care and cost modeling solution focuses on bringing together clinical intelligence, claims and other insights,” says Sood. “Evidence-based analyses help employers better understand risk and changes in clinical state, earlier in the timeline and then make more informed decisions around care. The future of digital health will depend on moving beyond individual point solutions toward broader and more actionable intelligence that helps actually manage complexity and improve outcomes via clinical intelligence, and more." Juggling these vendors was the focus of a Solera Health survey of 106 U.S.-based senior benefits leaders in mid-, large and major enterprises across various sectors, including healthcare. Forty-two percent of surveyed employers in the April 2026 report say they manage eight or more digital health vendors, and 90% report spending more than $1 million annually on costs. According to the report, the estimated median cost of managing digital health vendors is $580,000 on top of annual digital health benefits budgets. Sixty percent of organizations report that vendor management burdens have increased over the past three years, with 80% of benefits teams spending five or more hours per week on maintaining vendors. And 75% of respondents report that their organizations have two or more dedicated full-time employees for vendor management, and 81% have requested additional support.

The Right Plan Starts with the Right Partner 90 Degree Benefits helps brokers and employers manage the day-to-day work behind a strong health plan, from accurate claims administration to responsive member support. Set Up a y Consultation Toda

With national resources and localized service, we work alongside you to evaluate plan performance, identify opportunities, and consult on solutions designed around real needs. Claims Administration

Scan to start the conversation.

THE SELF-INSURER

Unique Plan Designs

Premier Customer Service Local Support

For organizations needing extra support, 72% report using outside consultants, brokers or third-party administrators and 60% of organizations spending $500,000 or more on external consultants still intervene on issues weekly or more. Surveyors conclude that when digital health is delivered as a curated network instead of a stack of point solutions, it eliminates the complexity at the source rather than hiring more people to manage the vendors. Barbora Howell, co-founder and CEO of TrueClaim, shares that she heard of a Fortune 500 company that hired consultants to gather data on which point solutions they had purchased and, “…they had 26 unique solutions in place, each with poor utilization rates. Recently, employers have become more interested in carve-outs and direct contracts, which allows them to deliver similar benefits directly within the health plan, driving higher utilization and ROI.”

Barbora Howell

To address these issues, companies are moving away from single-focus apps and are looking for allin-one navigation platforms to guide members. They are also using artificial intelligence (AI) to make recommendations. Howell maintains, “Integrated digital ecosystems are not a new idea. However, generative AI gives the market a renewed opportunity to build highly individualized experiences and finally drive the adoption needed to achieve results from members and employers alike. ”What’s even more arresting are reports that most employees are bypassing employer-sponsored programs and benefits and instead building their own ecosystem of digital tools – often at their own expense. Castlight Health's 2026 Employer Health Benefits Experience Survey shows a widening disconnect between the benefits companies offer and what employees actually use, despite significant employer investment in digital health and well-being programs. More than half of those surveyed use at least one consumer health or wellness app, and 46% pay out-ofpocket for solutions that feel more relevant or easier to use.

OCTOBER 2026

Esposito maintains that education and utilization are the most undervalued parts of the ecosystem. “Yes, there is vendor fatigue but no one will have fatigue if something is making an impact,” he emphasizes. “The fatigue sets in when there are solutions that are not being utilized and failing to deliver the ROI that is promised – this directly ties back to member education and communication of the plan. Member experience is critical. Apple took over the music and telecom space through ease of use and a consolidated offering with always reduce confusion.“ Employers aren’t alone in this experience as employees also experience vendor fatigue. Jenny Wan, director, Sales & Marketing, Health Portal Solutions suggests that every additional login and user interface increases friction. And friction reduces employee engagement. “Employers do experience vendor fatigue,” she notes. “Managing multiple vendor contracts, relationships, and platforms can quickly absorb an employer’s time and focus, leaving less time for managing health plan strategy. When engagement falls, program utilization declines, and ROI is underwhelming.” Wan says increasing program ROI is less about adding more digital tools and more about converting the tools we already have into one experience, adding, “When programs are organized into a unified, cohesive platform, they’re easier for employers to manage and more convenient for employees to access and use. Ultimately, this sets the stage for improving health outcomes and ROI.” Jenny Wan

Measurable Results. Lasting Impact. Prepping All Systems for Renewal Season Takeoff 1/1 decisions call for more than lofty promises. BRMS helps brokers and employers evaluate plan performance through administration expertise and actionable data, with the proof to back it up.

30+ years of industry expertise In-house systems built for clients and members Premier partnerships, vetted for efficiency 5:1 ROI on in-house care management

BRMS is Your Partner in Every Season. Learn more at brmsonline.com

THE SELF-INSURER

The best payment partner is the one you don’t see. Accurately delivering $220B+ a year to 1.6+ million payees. The infrastructure beneath healthcare for nearly 30 years.

She maintains that centralizing multiple platforms under one digital roof does not resolve every challenge associated with vendor fatigue, but it does address one of the biggest roadblocks: Ease of access. “Consumer behavior has proven that the more steps required, the less a user is likely to take action, says Wan. “This is especially true regarding employee participation in healthcare programs. An essential first step for employers to drive participation is giving employees ease of access to the programs.” When health resources are centralized, instead of spread out across multiple platforms, the employee experience becomes simple, more accessible, and inviting. The easier it is for employees to access their healthcare, the stronger the utilization will be. Ultimately, as program utilization grows, the positive outcomes from the program will grow as well. THE EVALUATION CHALLENGE

As part of a State of Healthcare 2024 study, sponsored by Quantum Health and conducted by Arizent, only 22% of employers fully trust that digital health tool vendors are acting in the employer’s best interest when sourcing better information and guidance for making health benefits decisions. Self-insured employers use digital health apps to manage chronic conditions and lower expensive doctor and hospital bills, but evaluating these tools is hard for several reasons. As the Castlight survey confirms, many employees prefer their own familiar health apps, meaning employer-provided tools often go unused. But it is fee misalignment that most seriously challenges vendor value, as many charge a flat "Per Employee Per Month" (PEPM) fee and get paid whether the tool actually helps the employee or not. Solera recounts that the PEPM model became popular in digital health because it was simple and predictable, offering a structure that made sense because it allowed employers to offer wide access to emerging tools without having to micromanage individual utilization. But today’s circumstances upend the traditional paradigms amid accelerating costs that demand greater accountability. Every dollar invested in a digital model must produce actual value, not simply theoretical access. They maintain that the real problem with PEPM pricing is that it completely misaligns incentives – and vendors get paid no matter what. There’s no built-in pressure for them to drive engagement or deliver better outcomes, so if employees don’t engage, participate, or complete programs, the vendor’s revenue stays exactly the same. This leaves employers in the unenviable position of covering costs for services that may be sitting idle while facing wasted budgets, overcrowded vendor rosters, and very little motivation for digital health partners to innovate or improve their performance.

THE SELF-INSURER

Solera contends that outcome-based pricing flips the equation so that employers pay for results, not simply access. Payments are tied directly to measurable success, whether that’s assessed by employees actually engaging with the program and demonstrating sustained behavior change or improving biometric markers and hitting pre-defined health milestones. Employers avoid paying for programs that aren’t working for their population and can take advantage of more sophisticated claims-based modeling and population health assessments that enable greater cost predictability. With greater clarity around success metrics, employers gain greater control, clearer reporting and a higher ROI. Certain digital point solutions certainly have the potential to generate measurable savings for self-insured employers by averting expensive escalations, emergency room visits, and physical health comorbidities. David Ostrowsky, manager, Corporate Communications, Phia, points to this prime example: the incorporation of telehealth appointments into the Direct Primary Care (DPC) healthcare model. “Under DPC, patients would pay a regular monthly fee—generally speaking, between $50-$150—and subsequently have access to an unlimited number of both in-person and virtual appointments with their respective physicians,” he explains. “The latter option is particularly effective for generating cost savings.” David Ostrowsky

He stresses that for the patient, everything associated with the telehealth appointment would be covered under that monthly fee—there would be no co-pays, nor would there be any additional fees for communication with one’s doctor. “That’s not to mention travel expenses (i.e., gas and parking) would be spared as well,” he adds. “Meanwhile, for self-insured plan participants, constant virtual access to care could motivate them to become more proactive in seeking care for relatively minor issues before they mushroom into ones necessitating ER visits. PROVING REAL VALUE

Digital health ROI is strongest when early intervention, high engagement and outcomes-based pricing work together to the benefit of the plan sponsor. Sword Health poses this question: Despite years of benefit investment, many organizations are still asking the same fundamental question: what are we actually getting for our spend? Sword analysts maintain that digital healthcare programs become a strategic requirement for plan managers looking to increase returns. Employers are no longer evaluating whether digital programs are interesting or innovative, they are now understanding the power of digital healthcare options that reliably change cost trajectories in ways that can be measured, forecasted and defended. The strongest digital health models do not simply expand access -- they reshape the cost trajectory itself by intervening earlier, keeping people engaged and aligning payment to outcomes rather than activity.

OCTOBER 2026

Finance leaders apply specific parameters for measuring ROI in digital health. CFOs aren't looking for adoption rates or feel-good testimonials when they evaluate ROI. Their real question is simpler: does this investment lower financial risk in ways that can be tracked, repeated and projected forward? In healthcare specifically, that question usually comes down to a handful of factors that impact the bottom line directly: •

Direct medical spend — costs avoided when imaging, injections, surgery, or specialist visits don't happen because care wasn't delayed or abandoned

•

Hidden workforce costs — absenteeism, disability claims, and productivity losses tied to pain or physical impairments that go unmanaged

•

Budget unpredictability — the risk that a small number of severe claims throws off annual cost projections

•

Speed of impact — whether results show up in months rather than years

If a digital health program can't tie its outcomes back to these specific levers, it won't hold up under finance scrutiny in the long-term. This distinction matters because it's precisely why so many conventional care approaches fall short on ROI. It’s not for lack of clinical value, but because they were never initially built to answer the financial questions.

THE SELF-INSURER

BEST PRACTICES TO PROVE VALUE

To evaluate if a digital tool truly works, self-insured employers should demand independent validation and look for proof from objective groups, such as the Validation Institute that reviews hard medical claims to see if a tool actually lowers health costs. It is critically important to tie payments to outcomes by shifting from flat PEPM fees to value-based pricing that rewards results. Vendors should only get paid the full price when an employee successfully completes a program or improves their health. Employers must ask vendors to prove specific outcomes rather than sell on potential capabilities.

TPAS AND BENEFITS BROKERS PROVIDE GUIDANCE

In their rapidly emerging roles as strategists, Third-Party Administrators (TPAs) and benefits brokers actively recommend digital health tools to their clients. As fiscal challenges build, many employers are turning to these advisors for clarity on what’s changing, what matters most right now and the opportunity to leverage AI solutions to analyze claims and personalize health benefits for different employees. Financial pressures naturally lead clients to look for more ongoing guidance as many clients want help understanding how costs or regulations could affect their plans and what options they have to adjust without adding unnecessary risk. However, brokers and TPAs have shifted their focus: Instead of recommending many separate tools, they now focus on centralized platforms that combine solutions in one resource. If a tool does not improve health or save money, they recommend dropping it. In 2026-2027, plan sponsors can tap these partners for recommendations on AI-powered navigation tools. These apps help employees find the right doctors, check symptoms, and understand costs without confusion. Expect suggestions for platforms that link virtual care, mental health apps and chronic condition management

Rather than contracting with multiple point solutions, plan sponsors should combine digital tools with a central healthcare navigation service that helps employees find the right digital tools and ensures utilization. Tracking clinical metrics is probably the most important activity for assessing ROI and bottom-line value. The key is to evaluate success by using real health numbers and measuring indicators such as drops in costly procedures -- like surgeries or ER visits -- or changes in medical markers -- like lower blood pressure or HbA1c levels.

OCTOBER 2026

into a single digital dashboard, with vendor consolidation at the root of this change. But employers have discovered that managing too many tools gets expensive and confusing, as advisors now help clients drop overlapping or unused apps in favor of unified systems. VERIFY THE MATH: DIGITAL HEALTH

ADOPTION REACHES NEW HEIGHTS

Analysts across the healthcare ecosystem project that digital health companies are positioned for a breakthrough year in 2026, driven by widespread AI adoption among enterprise customers. Health systems, health plans and employers are actively deploying and scaling AI in their operations, documentation and Shawn Evans care navigation – creating strong demand for digital health solutions that can integrate with and enhance these AI strategies. “In my experience, digital solutions by themselves do not work nearly as well as they could or should,” remarks Shawn Evans, CEO, Integrated Payor Solutions. If they are not able to work with all the other solutions as well as the claims systems, their effectiveness is limited. This is not due to the fault of company who came up with the solution, it is due to the lack of coordination between all of the systems.” He believes AI agents are a very current example. If you build the best AI agent to steer a patient to the best and most cost-effective care but the system that processes the prior auth information takes a few days to manually review the information and make a determination -- what is the point of the AI agent? “Even worse, if the prior auth is not part of the adjudication platform, you are waiting for someone to connect the dots and connect the member with the AI agent -- usually by calling or emailing the member,” he adds. “These solutions need to be real time for maximum effectiveness and the only way that can happen is when the information flows freely and via API. A biweekly file upload eliminates the efficiency gains by using an Agent.” Evans says if we can get real time continuous engagement between all the point solutions as well as the TPA and PBM, there will be significant savings.

THE SELF-INSURER

“However, this will entail significant system upgrades for many TPA’s and PBM’s,” he cautions. “Trying to build this out with a platform built over a decade ago simply will not work. These systems were built to be unique as they kept clients from moving or upgrading systems. When you are trying to integrate up to five platforms for a complex case and they are all unique, it is impossible to integrate all of them for maximum efficacy. In most cases it comes down to what do we need to get a working solution rather than best in class.”

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

COLD Rx MEDS

COST CONTAINMENT

TPAs & PBMs

BROKERS

Why is specialty drug spend still your #1 uncontrolled cost? Your GLP-1 spend has a fix. It’s defensible. It starts on day one. THE ONLY INTERNATIONAL SOURCING PROGRAM YOUR CFO CAN DEFEND AT THE BOARD LEVEL.

30–70% IMMEDIATE SAVINGS · FROM THE FIRST FILL · NOT A REBATE

MANITOBA IPS LICENSE The only Canadian province with a dedicated IPS licensing framework for international Rx fulfillment. Every order traced to a licensed pharmacist. Audit-ready.

BRAND-NAME ONLY No compounding. No grey market. Every drug DIN-matched to U.S. NDC — therapeutic equivalence confirmed on every fill.

COLD-CHAIN VALIDATED Temperature-controlled 2–8°C end-to-end, pharmacy to member door. 19-field dispensing records with every shipment.

$0 WORKFLOW CHANGE Overlays your existing PBM or TPA program seamlessly. Voluntary member opt-in. Savings begin on the first claim cycle.

BUILT FOR:

Third-Party Administrators

Self-Insured Employers

Cost-Containment Programs

Pharmacy Benefit Managers

Benefits Brokers & Consultants

Get a Free Drug-by-Drug Savings Analysis — 48 Hours. Confidential · No Commitment · coldrxmeds.com

ColdRxMeds · Manitoba IPS License · Brand-Name Only · Cold-Chain Validated · coldrxmeds.com

ERISA’S NEW FEE DISCLOSURE REQUIREMENTS FOR HEALTH PLAN SERVICE PROVIDERS

Written By Alston & Bird, LLP Health Benefits Practice

RISA requires plan fiduciaries to act prudently and to ensure that service arrangements are reasonable, that services are necessary for the establishment or operation of the plan, and that no more than reasonable compensation is paid. When these requirements are not satisfied, the plan fiduciary risks engaging in a prohibited transaction subject to costly penalties and excise taxes. The Department of Labor (“DOL”) has long taken the position that a fiduciary cannot meaningfully evaluate the reasonableness of aggregate compensation without information about both direct compensation (or fees) paid and also indirect compensation. ERISA’s fee disclosure requirement places the responsibility to disclose all such compensation on certain contracting service providers to covered plans. DOL regulations already require covered service providers of retirement plans to disclose compensation to plan fiduciaries. Congress extended a similar disclosure concept to certain brokers and consultants to ERISA-covered group health plans in CAA 2021 and expanded the definition of covered service provider in CAA 2026 to “clarify” that the disclosure obligation is not limited to only brokers and consultants, as many had previously assumed. The requirement now explicitly applies to almost any provider of the covered services listed in the statute, including providers of third-party administration (“TPA”) services and PBM services, stop-loss carriers, and ancillary vendors providing medical management, disease management, and employee assistance program services. 72

THE SELF-INSURER

Which plans are covered plans? ERISA-covered group health plans are covered plans subject to the new CAA 2026 rule. This includes not just major medical and pharmacy benefit plans, but also health flexible spending accounts (“health FSAs”), and health reimbursement arrangements (“HRAs”) (including excepted benefit health FSAs and ICHRAs), dental and vision plans, wellness programs, and employee assistance programs. Who is a covered service provider? A covered service provider is a service provider that enters into a contract or arrangement with a covered plan and reasonably expects to receive at least $1,000 in direct or indirect compensation for providing covered services under the contract or arrangement, regardless of whether the services will be performed, or the compensation received, by the covered service provider, an affiliate, or a subcontractor. The legal obligation to disclose fees to the plan fiduciary is on the service provider that enters into the contract or arrangement with the covered plan, even if other parties perform some of the services. However, that entity is required to take into account compensation (direct and indirect) received by its affiliates and sub-contractors as well. Covered services, which CAA 2026 clarified do not have to be performed by a broker or consultant, include: 

Plan design and consulting;



Insurance and insurance product selection, including medical, dental, and vision products;



Recordkeeping;



Medical management and disease management programs;



Benefits administration and vendor selection, including dental and vision;



Stop-loss insurance;



PBM services;



Wellness program design, management, and related services;



Price transparency tools and vendors;



Group purchasing organization arrangements and services;



Preferred vendor panel participation and related services;



Compliance services;



Employee assistance programs; and



TPA services such as processing claims.

OCTOBER 2026

Who is an affiliate or subcontractor? Compensation received or reasonably expected to be received by affiliates of the covered service provider must also be disclosed by the contracting service provider, if received in connection with the covered services. An affiliate is an entity that directly or indirectly (through one or more intermediaries) controls, is controlled by, or is under common control with, the covered service provider, or is an officer, director, or employee of, or partner in, such provider. The disclosure requirement also applies to compensation from downstream contracts or arrangements to the extent the subcontractor is performing covered services described in the agreement with the plan. A subcontractor is any person or entity (or an affiliate of such person or entity) that is not an affiliate of the covered service provider and that reasonably expects to receive $1,000 (subject to adjustment for inflation) or more in compensation through a contract or arrangement with the covered service provider for performing one or more covered services. When analyzing under the fee disclosure requirements, it is important to determine whether the service performed by the affiliate or subcontractor is both listed in the statute and part of the arrangement between the covered service provider and the plan.

Is Your IDR Strategy Ready for the Big Leagues? Across the Field

6.3M 3-5X 10-30X

IDR Disputes Initiated Since 2022 Higher Provider Demands Gaps in Certain Specialties

Phia’s Performance at the Plate

76%

2.5X 3X

Average Savings*

More NSA Savings**

More NSA Wins**

*Subject to claim mix and provider billing practices **Based on an industry study of Independent Dispute Resolution (IDR) decisions

When providers are swinging big in IDR, health plans need the right team behind them. phiagroup.com | info@phiagroup.com

THE SELF-INSURER

of Strength You Can Count On For two decades, Berkley Accident and Health has helped organizations manage risk with strong protection and data-driven insights.

Built on financial strength

Proven through experience

A+ (Superior) rated and a member of a Fortune 500 organization1

Leader in Stop Loss, Group Specialty Accident, and Managed Care

Driven by insight Direct writer1 dedicated to innovation and transparency

Twenty years in, and we’re still focused on the future. To learn more, contact your Berkley Accident and Health representative or visit www.BerkleyAH.com.

Berkley Life and Health Insurance Company and StarNet Insurance Company are rated A+ (Superior) by AM Best. Berkley Accident and Health is a member of W. R. Berkley Corporation, a Fortune 500 company.

Stop Loss is underwritten by Berkley Life and Health Insurance Company and/or StarNet Insurance Company, both member companies of W. R. Berkley Corporation and rated A+(Superior) by A.M. Best, and involves the formation of a group captive insurance program that involves other employers and requires other legal entities. Berkley and its affiliates do not provide tax, legal, or regulatory advice concerning EmCap. You should seek appropriate tax, legal, regulatory, or other counsel regarding the EmCap program, including, but not limited to, counsel in the areas of ERISA, multiple employer welfare arrangements (MEWAs), taxation, and captives. EmCap is not available to all employers or in all states. Payment of claims under any insurance policy issued shall only be made in full compliance with all United States economic or trade and sanction laws or regulation, including, but not limited to, sanctions, laws and regulations administered and enforced by the U.S. Treasury Department’s Office of Foreign Assets Control (“OFAC”).

BAH AD 2025-231

www.BerkleyAH.com

What is compensation? Compensation is broadly defined to mean “anything of monetary value,” but excludes non-monetary compensation valued at $250 or less, in the aggregate, received during the term of the contract or arrangement. •

Direct compensation: Compensation received directly from the covered plan.

•

Indirect compensation: Compensation that the covered service provider, or its affiliate or subcontractor, reasonably expects to receive in connection with services to an ERISA-covered group health plan from a source other than the plan, the plan sponsor, the covered service provider, or an affiliate of the covered service provider. Compensation received from a subcontractor is indirect compensation, unless it is received in connection with services performed under a contract or arrangement with a subcontractor.

This “in connection with” concept is to be construed broadly; to the extent a covered service provider reasonably expects that compensation will be received based in whole or in part on its service arrangement with the covered plan, the compensation will be considered received in connection with that arrangement. For example, a service provider failed to disclose a $20,000 subsidy paid by a financial institution to support a client conference for which plan sponsor attendees paid an $850 registration fee. The DOL considers such subsidies or similar remuneration from financial institutions that may be the subject of the provider’s recommendations to plan sponsors to be compensation received “in connection with” the provider’s arrangement with a covered plan.

Don’t be like him - you need to take action to address your fiduciary responsibility.

Pharmacy auditing and ongoing claims monitoring: 917-359-9592 | gregg.lambert@caribousystems.com

THE SELF-INSURER

How must compensation be described? If compensation cannot be expressed in exact monetary amounts, ERISA allows formulas and/or a per capita charge. If none of those methods work, the disclosure can be made by any other reasonable method. If the possibility of earning additional compensation is known but cannot be calculated in advance, a description of the circumstances for earning the additional compensation that includes a reasonable and good-faith estimate, along with an explanation of the underlying methodology and assumptions, is acceptable. Ranges Allowed for Variable Compensation. In analogous guidance, DOL views disclosure in ranges as reasonable when features of the arrangement could cause compensation to vary within a projected range, but more specific compensation information is preferred whenever it can be furnished without undue burden. Payer Identity Unknown in Advance. For retirement plans, DOL has recognized that the identity of a specific payer of indirect compensation may not be known in advance. In those circumstances, a disclosure may describe the compensation in general terms if it contains enough information for the plan fiduciary to evaluate in advance of the arrangement. What are the content, format and timing requirements? DOL is supposed to issue regulations addressing the time, manner, and content of the fee disclosures. Some service providers take the position that disclosures are not required until DOL issues those rules. However, the statute supplies some of this information already. Content Covered service providers should prepare to disclose the following information listed in the statute: •

Description of the services to the covered plan under the contract/arrangement.

•

ERISA fiduciary status, if applicable.

•

Description of all expected direct and indirect compensation, including the payer’s identity, services generating the compensation, and a description of the arrangement. Include indirect compensation from a vendor to a brokerage firm based on an incentive structure not solely related to the plan contract.

•

Description of transaction-based compensation paid among related parties—e.g., commissions, finder’s fees, or similar incentive based on business placed or retained; identify the services, payers, recipients, and affiliate/subcontractor status.

•

Description of termination compensation and explain how any prepaid amounts will be calculated and refunded on termination.

•

Description of how compensation will be received—for example, whether paid directly, billed, deducted, retained, or otherwise received.

Generally, the adequacy of a disclosure will be evaluated by whether it allows plan fiduciaries to assess the reasonableness of compensation and the severity of any associated conflicts of interest. The covered service provider must also timely disclose any other compensation-related information needed for ERISA reporting/disclosure compliance if the fiduciary or plan administrator asks for it in writing. OCTOBER 2026

Format Fee disclosures must be in writing. The DOL has not provided any model form and has expressed that it is unlikely to provide such a form for fee disclosures to group health plans. Generally, disclosures are not required to be provided in a single document. Prior DOL preambles state that required information may be furnished through different documents from separate sources if the documents collectively contain the required information. A summary, guide, index, or roadmap is optional, not required, but may be a useful best practice where disclosures are lengthy or spread across multiple documents. Electronic delivery is permissible, including through a secure website, if the information is readily accessible to the responsible plan fiduciary and the fiduciary receives clear notice on how to access it. Timing The initial disclosure must be provided reasonably in advance of the date the contract or arrangement is entered into, extended, or renewed. After the initial disclosure, the covered service provider must disclose changes no later than 60 days after the provider is informed of the change (or sooner if practicable), unless extraordinary circumstances beyond the provider’s control prevent disclosure, in which case disclosure should be made as soon as practicable.

Employees are unique. Their health plan should be, too. Together, we anticipate your population’s needs through: • In-house support from implementation to renewal • Smarter cost-control with fully vetted point solutions • Strategic guidance with scalable plans and network options

hpiTPA.com

THE SELF-INSURER

Not just a TPA—a partner.

STOP LOSS INSURANCE

WE’LL HELP MANAGE THE RISK. YOU’LL KEEP YOUR PROMISES. Prudential’s Stop Loss insurance helps reduce unpredictable risks from self-funded medical plans. This way you can focus on giving your employees the coverage they deserve, while helping to reduce your worries about the increased frequency of catastrophic claims. Get Stop Loss insurance from a carrier you can rely on: • A highly rated, experienced carrier recognized for over 150 years for strength, stability, and innovation • Efficient, responsive service with streamlined processes across quoting, onboarding, and reimbursements • A dedicated distribution team that works hand-in-hand with your existing relationships • Flexible policy options so we can build a coverage plan that meets the unique needs of your organization

See how Prudential can help you manage the risk from your self-funded medical plan. For more information, visit our website: www.prudential.com/stoploss

Prudential Stop Loss policy options may vary by state. Contact your Prudential representative for more information. Group Insurance coverage is issued by The Prudential Insurance Company of America, a Prudential Financial company, Newark, NJ. © 2026 Prudential Financial, Inc. and its related entities. Prudential, the Prudential logo, and the Rock symbol are service marks of Prudential Financial, Inc., and its related entities, registered in many jurisdictions worldwide. 1081937-00003-00 NOT11_AD_GI47_01

What if the service provider makes a mistake? Errors and omissions alone are not fatal to compliance as long as a covered service provider acts in good faith and with reasonable diligence, and if the provider discloses the corrected information to the responsible plan fiduciary as soon as practicable and no later than 30 days after the provider knows of the error or omission. What if a plan fiduciary discovers a disclosure failure, or the covered service provider fails to comply? A plan fiduciary has a responsibility to request from the covered service provider, in writing, any missing information it discovers has not been disclosed. If the provider fails to comply within 90 days, the fiduciary must notify DOL within 30 days after the earlier of refusal or the end of the 90-day period and must determine whether to terminate or continue the arrangement. If the missing information relates to future services and is not disclosed promptly after the 90-day period, the fiduciary must terminate the arrangement as “expeditiously as possible,” consistent with its duty of prudence. Note the emphasis here is not simply on the act of disclosure but on the purpose of the disclosure itself. For a responsible plan fiduciary, the disclosure of compensation is mandatory to adequately assess the reasonableness of the arrangement for purposes of the statutory exemption from a prohibited transaction. If the covered service provider fails to disclose required compensation, the arrangement risks losing exemption protection unless the statutory error-correction rule applies. A non-exempt arrangement implicates ERISA’s prohibition against the furnishing of goods, services, or facilities between the plan and a party in interest. PRACTICAL PLANNING STEPS

The expanded disclosure framework under ERISA §408(b)(2) places the disclosure responsibility on the service provider that contracts directly with the plan, but that responsibility extends to compensation received by affiliates and subcontractors in connection with plan services. As a practical matter, service providers should consider implementing a structured process to identify covered plans, identify relevant compensation streams, gather information from affiliates and subcontractors, and prepare disclosures using reasonable and good-faith methodologies where precise information is unavailable.

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

THE SELF-INSURER

Employer Stop Loss: Limit Health Care Exposure. Advancing Self-funding Together.

Experience exceptional customer service and top-tier stop loss coverage with Swiss Re Corporate Solutions. Our steadfast dedication to our clients ensures a seamless business experience. We streamline stop loss coverage, addressing industry challenges to help move you forward. Discover smarter, faster and better stop loss solutions tailored to you. corporatesolutions.swissre.com/esl

NEWS

NEWS FROM SIIA MEMBERS OCTOBER 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. ClaimsBridge Announces New Investment & Acquisition ClaimsBridge, a leading provider of end-to-end claim and network technology solutions for TPAs, networks and employers, announced two milestones in its growth strategy: with investment bank, Ansley Capital, ClaimsBridge secured a strategic investment from Eir Partners Capital (Eir), a private equity firm focused on healthcare technology and tech-enabled services, and completed the acquisition of DialysisPPO, with investment bank Bailey & Co, a company specializing in cost containment for End-Stage Renal Disease (ESRD) and chronic dialysis treatment. 82

THE SELF-INSURER

NEWS According to a company statement, Eir's investment builds on ClaimsBridge's strong foundation, bringing capital and a proven track record of building healthcare technology platforms. ClaimsBridge garners both savings and efficiencies, with their AI enhanced Celerity engine that offers a single vendor pre-adjudication claim workflow. Operationally, nothing changes for clients: the same team, processes, and standards of excellence in service remain in place. Alongside the investment, ClaimsBridge has acquired DialysisPPO. Founded in 2006, DialysisPPO has helped payers save more than $325M through a patented program that allows plans to capture Medicare savings on dialysis claims. With this acquisition, ClaimsBridge clients gain direct access to the specialized, patented solution for one of the highest-cost chronic conditions, alongside ClaimsBridge's existing cost management solutions. "This is an important moment for ClaimsBridge," said Kevin Gibson, CEO of ClaimsBridge. "Eir's investment gives us the ability to accelerate innovation for our clients and the payer market, and DialysisPPO is the strongest solution we've seen for one of healthcare's most complex and expensive conditions. Together, these moves reflect where we're headed: simplifying complexity and taking cost out of the healthcare system." "Joining ClaimsBridge allows us to bring our ESRD savings program to a much broader base of payers, backed by ClaimsBridge's technology, network reach, and client service model. Just as important, our existing clients now gain access to a full suite of proven cost management solutions alongside the program they already rely on," said John Brophy, the CEO and Founder of DialysisPPO.

OCTOBER 2026

NEWS Zenith Names New Leader for Business Development Team Zenith American Solutions announced the appointment of Alan Wiederhold as Chief Client Relations & Business Development Officer. Wiederhold joins Zenith with more than 30 years of experience across healthcare, insurance, and third-party administration. Prior to joining Zenith, Wiederhold served as President of a medical stoploss insurance company, where he led the organization through a period of meaningful innovation. Under his leadership, the company introduced a first-of-its-kind mental health program, developed a stop-loss warranty and two-year rate guarantee, and launched international pharmacy solutions designed to help members access critical medications at substantially lower cost. These initiatives reflect a consistent theme in Wiederhold's career: a belief that better solutions are always possible, and a willingness to build them.

Alan Wiederhold Zenith American Solutions

“I am honored to join an organization with such a strong and principled foundation.” My career has been driven by a belief that the work of administration — done well — has real consequences for real people. I look forward to deepening the relationships Zenith has built and helping bring forward solutions that continue to raise the standard of service our clients and members deserve,” said Wiederhold.

Turn Momentum into Meaningful Progress Bring Your Best Ideas to Life At SIIA, the conversation is about what’s next. IPS is helping organizations get there with modern claims administration technology. AI-Assisted Implementation

Configurable Automation

Embedded Compliance

Cloud-Based on Salesforce

Visit IPS at Booth #901 SIIA National Conference | October 11-13

THE SELF-INSURER

Scan to Schedule Time with Our Team integratedpayorsolutions.com

Risk has nowhere to hide. When pricing pressure is everywhere, you can’t afford to miss any risk. Only Curv exposes the catastrophic claims lurking behind group health data so you can make high-stakes stop loss decisions with confidence. rxhistories.com/curv/group-health

Milliman Curv

NEWS

“Alan brings a rare combination of operational depth, industry expertise, and genuine care for the people this industry serves. His experience across every facet of benefits administration, his personal connection to the labor community, and his track record of thoughtful leadership make him an exceptional addition to the Zenith team,” said Kim Fiori, Chief Executive Officer & President, Zenith American Solutions. Capterra Executive Team Expands with New Managing Director Appointment Capterra Risk Solutions has announced the appointment of Nicole McCabe as managing director. McCabe brings more than a decade of experience helping organizations evaluate, design and manage captive insurance and alternative risk financing programs, spanning domestic and offshore domiciles, a range of captive structures and clients from privately held businesses through to Fortune 100 companies. She joins from Straight Arrow Risk Consulting, an advisory firm specializing in alternative risk, captive insurance strategy and risk diagnostics for middle-market and enterprise organizations, which McCabe founded and led as president. Earlier roles include vice president, risk solutions, and senior captive consultant at Brown & Brown, president of Captive Consulting Partners, and vice president and executive underwriter at International Captive Consulting.

At Meritain Health®, we know every health journey is di�erent. For over 40 years, we’ve made it our mission to help customers and members get the most from their health bene�ts—wherever their path takes them. Best of all? We focus on creating simple, transparent and versatile bene�ts that work hard, making staying healthy easier and more a�ordable.

THE SELF-INSURER

ALL SYSTEMS

2026 SIIA NATIONAL

CONFERENCE Title Sponsor

October 11-13, 2026 JW Marriott Desert Ridge Phoenix, AZ THIS is where the business of self-insurance gets done.

NEWS The Difference Card Acquires HealthCorum The Difference Card, a leading provider of cost-effective health insurance solutions, announced that it has acquired HealthCorum, a healthcare data analytics company known for its provider quality scores, insights, and navigation technology that help organizations guide members to high value care. Joseph Donovan, Chief Executive Officer of The Difference Card, said, “For 25 years, The Difference Card has helped employers control healthcare costs without compromising on the quality of benefits offered to their employees. By bringing HealthCorum’s industry leading provider analytics, quality scoring, and AI powered navigation capabilities into our platform, we are taking another significant step forward in that mission.” HealthCorum President and Chief Executive Officer, U.N. Amighi, expressed excitement about the acquisition, stating, “HealthCorum was founded on the belief that better healthcare decisions, improved outcomes and lower costs begin with better data. Joining The Difference Card allows us to expand the reach of our provider intelligence platform and accelerate its adoption in tools that help patients identify high quality, cost-effective care. We share a common vision of improving healthcare affordability while enhancing the member experience, and we are excited to help shape the future of healthcare together at The Difference Card.”

THE SELF-INSURER

THE STOP LOSS ENGINE

BEHIND YOUR PROGRAM Supporting Brokers & TPAs Experienced underwriting, access to A+ rated carrier partners and deep network intelligence to help find the right solution for each client. Backing Health Plans & Carriers Private-label underwriting, clinical, actuarial and operational expertise built to strengthen and scale stop loss programs. mrmstoploss.com

NEWS HM Insurance Group Announces Key Addition to Underwriting Team HM Insurance Group (HM) has named Jonathan Becker, senior vice president, Underwriting, for HM Insurance Group (HM). In this role, Becker will lead the development, execution, and oversight of HM’s Stop-Loss underwriting and pricing strategies to support the company’s overall business objectives. “Adding Jon to our team strengthens our underwriting leadership and positions us for success,” said Mark Lawrence, president, HM Insurance Group. “His extensive experience and strategic expertise will help ensure we continue to deliver exceptional value to our partners and clients."

Jon Becker HM Insurance Group (HM)

Prior to HM, he served as senior vice president, Employee Benefits Underwriting, at Voya Financial, where he was responsible for underwriting Stop-Loss, Group Life, Short-term Disability, and Supplemental Health products. He also served as vice president, Regional Underwriting, for Tokio Marine HCC, where he led the underwriting of Stop-Loss and Captive Stop-Loss business. Jon holds a Bachelor of Arts degree in Finance from Iowa State University.

THE SELF-INSURER

NEWS Mike Hughes to Lead Specialty Business at Berkley A&H Berkley Accident and Health has appointed Mike Hughes as Divisional President of its Specialty Accident business. In this new role, Mike will be responsible for leading the continued growth and momentum Berkley Accident and Health has established in the Specialty Accident marketplace. “I’m thrilled to welcome Mike to Berkley Accident and Health,” said Brad Nieland, President and CEO of Berkley Accident and Health. “Mike brings deep industry expertise, a proven track record of leadership, and a strong Mike Hughes understanding of our market. His experience complements our talented team Berkley Accident and Health and further strengthens our ability to serve brokers and clients. With Mike’s leadership and involvement, we are well-positioned to accelerate the growth of our Specialty Accident business and capitalize on the significant opportunities ahead.” With 20 years of experience in the accident insurance industry, Mike’s background spans underwriting, product development, and distribution. Prior to joining Berkley Accident and Health, Mike held leadership roles at a major insurance carrier, where he was responsible for strategy for Corporate Accident and Special Risk Accident products.

OCTOBER 2026

NEWS H.H.C. Group Names New Business Development Manager H.H.C. Group (H.H.C.), a leader in reducing healthcare expenditures through cost containment and independent review solutions, announces that Patrick J. Fabrizio has joined the company as Business Development Manager. According to a company statement, Fabrizio will support H.H.C.’s growth by developing relationships throughout the payor ecosystem, including insurance companies, TPAs, self-insured employers, benefits brokers, case management organizations and workers’ compensation organizations. “Patrick brings a valuable combination of healthcare account management, benefits implementation and consultative sales experience,” says Bruce D. Roffé, P.D., M.S., H.I.A., President and CEO, H.H.C. Group. “He understands how to identify a client’s operational challenges, present clinical and financial solutions and build the longterm relationships essential to delivering measurable value. His experience increases our ability to connect more organizations with H.H.C.’s cost-containment services.” Fabrizio has more than 10 years of combined experience across healthcare, insurance, sales 92

THE SELF-INSURER

and entrepreneurship. At CareFirst BlueCross BlueShield, he managed 120 fully insured employer accounts and helped develop renewal and plan-design strategies across a portfolio exceeding $25 million. He later served as an Implementation Manager at PBIRx, where he coordinated pharmacy benefit programs and cost-saving initiatives for self-insured employer groups, working with brokers, TPAs, PBMs, clinicians and other benefits partners.

Patrick Fabrizio H.H.C. Group

Facilitating business in the Self-Insurance/Captive Insurance industry.

Connect with leading TPAs, stop-loss carriers, captive managers, and industry solutions providers. Explore upcoming events and read relevant articles.

SIIA Member Value SIIA members receive one complimentary listing which can be featured in up to three categories.

Get Listed!

2026

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

BOARD MEMBER

Amy Gasbarro President 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 as Director

THE SELF-INSURER

Cell and Gene Task Force Ashley Hume President Emerging Therapy Solutions®

Let’s build a smarter benefits strategy Join the thousands who trust Nationwide® to deliver valuable employer solutions. Our expert teams can help build a better self-funded, cost-containment strategy that delivers meaningful and comprehensive benefits to employees.

Why work with Nationwide®? Experience We have over 20 years of experience in the self-funded, stop loss and voluntary benefit spaces

Partnership and support Our teams and partners provide personal and professional support to agents, employers and employees

Customizable You can tailor plan designs to meet the needs of small to midsize businesses

Get support and expertise where you need it most. Learn more at nationwide.com/grouphealth.

The Self-Funded Program through Nationwide provides tools for employers owning small to midsize businesses to establish a selffunded health benefit plan for their employees. The benefit plan is established by the employer and is not an insurance product. Stop loss insurance policies are underwritten or reinsured by Nationwide Life and Benefits Insurance Company. Refer to nationwide.com/ stoplossdisclaimer for details. Product availability and specific provisions may vary by state. Nationwide and the Nationwide N and Eagle are service marks of Nationwide Mutual Insurance Company. © 2026 Nationwide GHM-0349AO (06/26)

SIIA NEW MEMBERS CORPORATE MEMBERS:

Maurica Askew Vice President of Sales & Marketing PharmaCentra LLC Alpharetta, GA Antonio Cahue, JD Director, Employer Networks Orlando Health Orlando, FL Kate Careaga Director of Operations HealthBook+ Denver, CO Brad Cillian GM Employer Solutions Upside Boca Raton, FL James M. Deren President Carelink DME, LLC Wesley Chapel, FL Semih Gultekin CEO Kanurra New York City, NY Ashish Jaiman Founder & CEO Nedl Labs Clarksburg, MD

THE SELF-INSURER

Sudha Kaki Managing Partner Pepcus Software Services, Inc. Austin, TX

Greg Rable CEO OffPlan Marietta, GA

James M. Knox Vice President Eagles, Benefits by Design, Inc. Tampa, FL

Jodd Readick CEO Clarify AI, Inc. Los Angeles, CA

Evan Mendez Co-Founder & Partner Aldaron San Francisco, CA

Jessica Reid Head of Go To Market Operations OpenNetworks Wilmington, DE

Taylor R. Miller CEO The Wellness Vault LLC Indianapolis, IN

Johannes Robinson-Cloete Managing Member Ubi Cras Consulting, LLC Holicong, PA

Sanat Mohapatra CEO Vasquez Roswell, GA

Dan Rozenfeld Investor Integrum New York, NY

Michael Palmer Account Director eMed Miami, FL

Amy Slizofski Senior Executive Assistant Transformation Capital Boston, MA

Jason B. Pearce Senior Director Miller Insurance London, United Kingdom

Mark Tanner President Insurance Strategies Consulting Ankeny, IA

% !#" $ $ " #" ¼Ø×Ûà£ÖÑÊÏ¼ØÑÏ£Ì¼ ¼ØÊÜËÓ¦×É£¼É £Ö×ÜÌ¼ Û¼ ×Ë£ÖÉ¼ÑÆ£ÖÖÓØØ£Û¼×É¼É £¼¦ÑÊÛÉ£ÖÌ¼ ¼ØÖÊà¼É ×É¼ ¦ÑÏÉÏ¼ÑÊ¼¾ÑÖ£¼×ÛØ¼ØÑ£Ï¼ÑÊÖ¼¾£¾ã£ÖÏ¼ ×Ö¾Ì¼¿·Õµ±Õ¯±âÅ½«µ±È½§±ÕÂÃ±½¤¹Î¯Å½ µÂÎ³¹«¡ ¹Ò¡«¹Â·ÎÅ½¡·â½³¤±Þ±·«¡§ ±½³ ¡·½Î³±·â®½ ÚÎ½ÈÂ©¤½³µ¡¤Ã¡ÕÈ½§±·± ¹«½§©¹ «½«Â½³¤Â«±Õ«½ ¡ ¡¹·Î«½«µ±ÃÅ½Â¤½ ©Î«½«Â½³¡È½ Â¤½«µ±Ã» ß´ ¢Áß¸Ðº¸Íº ¶º¸¶á°²°¶á°¶ªÄºÔ ¸¶¸Ô¸ ¶ °áº ßÙ ºª´ ªº ²² ¸°ÍºÔ ¸¶¸Ô º ¶áºÔÀÍªº¸¶ª° ¸ °¶Ô°º ªÀº°Ý°¢ÇºÔ ¸Áº ªºª´°º²À¸¶ªºÀ º á ¨á¸Ô ª¸À¶º ¥° À¢°º¸ª Íº² ¸á¬

m k d _ ^ _ kf Z Xf d _ ^ _ kf d

ptrtqsonon :6537.-218/,2.48+*-98(9'6)3. &)+*+&6).08*+-81+*,

yxwvxu

C5316,3.'43&+6)-G.'65+*,'

VR*37.426106&+3'

3&8,*+ 37.(81.&)+*+&6).+**856-+8* .(81.036'/1+*,. R26-.R6'.41353*-37 .*8-.{/'-.R26-.R6'.46+7z

2026

BOARD OF DIRECTORS

Dani Kimlinger CEO & Partner MINES & Associates

Liz Midtlien Head of Large Claims Solutions BCS Financial Corporation

Jonathan Socko President East Coast Underwriters, LLC

Les Boughner Chairman Advantage Insurance

Matt Hayward Office President Ryan Specialty

Nigel Wallbank SIEF Chairman Emeritus

Let us help you discover smarter strategies for controlling costs and improving outcomes.

Turn Benefits Into a Business Advantage. PAISC.COM

THE SELF-INSURER

More tools won’t fix a disconnected experience TPAs need technology that connects the dots — across costs, claims, payments and member experiences.

Less friction. Clearer decisions. Better outcomes.

Scan to see what digital transformation should prioritize next.

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

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