David Cook | Self-Funded Health Plans

Helping employers stop overpaying for healthcare. Self-funded and captive health plans. Health Rosetta Advanced Advisor. NABIP Self Funded Certified.

[David Cook | Self-Funded Health Plans @DCookBenefits]

@molsjames Employers run into the same problem from the other side. Hospital quality scores get handed to plan sponsors as a reason to steer employees, and a lot of them measure whether boxes got checked. I'd rather see complication and readmission rates by procedure and by surgeon.

[David Cook | Self-Funded Health Plans @DCookBenefits]

Your math checks out for cleanings alone. Where dental coverage usually earns its keep is the network fee schedule and the bigger work, like crowns and root canals, up to the annual max. If you only ever need cleanings, a plan with preventive at 100% and no deductible, or cash, may beat it.

[David Cook | Self-Funded Health Plans @DCookBenefits]

Some surgery centers skip the phone tree entirely and post an all-in cash price online, with the surgeon, anesthesia, and facility included. Employers can use those prices too. A self-funded plan can pay the posted price directly and waive the deductible for the employee who goes there.

[David Cook | Self-Funded Health Plans @DCookBenefits]

@PaulHFlowersJr The PBM’s answer is usually that dropping rebate guarantees means a higher net cost, and they show a spreadsheet to prove it. Most employers can’t check that math without claims-level data. Get the data rights in the contract first, then the fee fight gets a lot easier.

[David Cook | Self-Funded Health Plans @DCookBenefits]

Medicare has proposed paying PBMs a flat fee in Part D instead of a cut tied to drug prices and rebates. That rule doesn't cover employer plans. A self-funded employer doesn't have to wait... it can write flat fees and full rebate pass-through into its own PBM contract now.

[David Cook | Self-Funded Health Plans @DCookBenefits]

Question for anyone on an employer health plan. Would you take a plan with fewer doctors and hospitals if the ones on the list cost you $0?

A new WTW survey found 58% of employees would rather pay more out of pocket than accept more restrictions. I'd like to hear why.

[David Cook | Self-Funded Health Plans @DCookBenefits]

Walmart will cover Ozempic and Mounjaro at no cost in 2027 for employees with type 2 diabetes. Weight loss alone won't be covered.

If it were your health plan and your money, where would you draw the line on GLP-1s? Diabetes only, both, or neither?

[David Cook | Self-Funded Health Plans @DCookBenefits]

@Riley_Gaines_ The employer side has the same problem. In a self-funded plan the business pays the claims, but the price sits in a network contract it usually never sees. Ask your TPA for the allowed amounts on your top 20 procedures and put a surgery center's posted cash price next to them.

[David Cook | Self-Funded Health Plans @DCookBenefits]

Six big employers just sued UnitedHealth in federal court in Texas over how it ran their self-funded plans. Part of what they want is their own claims data.

If Kraft Heinz has to sue to see what its plan paid, a 200-person company should read its audit and data clauses now.

[David Cook | Self-Funded Health Plans @DCookBenefits]

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

[David Cook | Self-Funded Health Plans @DCookBenefits]

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

[David Cook | Self-Funded Health Plans @DCookBenefits]

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

[David Cook | Self-Funded Health Plans @DCookBenefits]

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

[David Cook | Self-Funded Health Plans @DCookBenefits]

Heads up, Texas. ACA open enrollment starts Nov. 1. If you use an agent on https://t.co/vYSg4UiH05, you'll get a code by text, email, or call to approve them. New, moved, switched agents, or paying $30 a month or less? You verify your ID first. Don't ignore that code.

[David Cook | Self-Funded Health Plans @DCookBenefits]

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

[David Cook | Self-Funded Health Plans @DCookBenefits]

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

[David Cook | Self-Funded Health Plans @DCookBenefits]

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

[David Cook | Self-Funded Health Plans @DCookBenefits]

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

[David Cook | Self-Funded Health Plans @DCookBenefits]

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

[David Cook | Self-Funded Health Plans @DCookBenefits]

A primary care visit is a primary care visit, right? HCCI found one averaged $116 in a physician office and $217 billed as hospital outpatient.

Employers, have you ever checked how much of your plan's primary care gets billed the second way?