Self-Funding Mastery: The Complete Employer Guide to Self-Insured Health Plans

Understand the fundamental economics, legal framework, and strategic advantages that make self-funding the dominant model for mid-to-large employer health plans.

• The Economics of Self-Funding: Where the Money Goes9 min
• ERISA Preemption: The Legal Foundation of Self-Funding8 min
• Strategic Advantages: Data, Control, and Customization8 min

Master the vendor ecosystem of a self-funded health plan — understanding the roles, relationships, and fee structures of TPAs, networks, PBMs, and stop-loss carriers.

• The TPA: Your Plan Administrator9 min
• Networks and Reference-Based Pricing9 min
• PBM Structure and the Transparency Imperative9 min

Master the mechanics of specific and aggregate stop-loss insurance — understanding attachment points, lasers, contract terms, and carrier selection.

• Specific Stop-Loss: Individual Claim Protection9 min
• Aggregate Stop-Loss and Cash Flow Protection8 min
• Stop-Loss Contract Terms and Carrier Selection8 min

Learn to extract, analyze, and act on self-funded plan claims data — identifying cost drivers, measuring trends, and building data-driven cost-containment strategies.

• Understanding Your Claims Data: Structure and Sources8 min
• Cost Driver Analysis: Finding the Signal in the Noise9 min
• Trend Analysis and Forecasting8 min

Develop a comprehensive pharmacy benefits strategy — from PBM contract optimization and specialty drug management to biosimilars, formulary design, and emerging drug cost threats.

• PBM Contract Optimization: From Opaque to Transparent9 min
• Specialty Drug Management: The $1M Problem9 min
• Biosimilars, Formulary Design, and Emerging Threats8 min

Design a high-performance self-funded health plan using value-based benefit design, Centers of Excellence, Direct Primary Care, and advanced network strategies.

• Value-Based Plan Design: Aligning Incentives with Evidence9 min
• Centers of Excellence and Bundled Payments9 min
• Direct Primary Care and Advanced Primary Care Models8 min

Navigate the federal compliance landscape for self-funded health plans — ERISA fiduciary duties, ACA requirements, CAA 2021 mandates, and the No Surprises Act.

• ERISA Fiduciary Duties: The Plan Sponsor's Legal Obligations9 min
• ACA and CAA Requirements for Self-Funded Plans9 min
• Mental Health Parity: The Most Enforced Compliance Requirement8 min

Implement evidence-based cost containment programs — from utilization management and case management to musculoskeletal management and second opinion programs.

• Utilization Management: Prior Auth, Concurrent Review, and Case Management9 min
• Musculoskeletal Management: The Highest-ROI Cost Containment Program9 min
• Care Navigation and Telemedicine8 min

Build a comprehensive mental health benefits strategy — addressing MHPAEA compliance, access barriers, substance use disorder treatment, and the total cost of mental health conditions.

• The Mental Health Crisis: Scope, Cost, and Employer Impact8 min
• Modern Mental Health Platforms: Beyond the EAP9 min
• Substance Use Disorder: The Hidden Cost Driver8 min

Separate wellness program evidence from hype — identifying the interventions that generate real ROI and designing a prevention strategy that addresses your population's actual health risks.

• Wellness Program Evidence: What Works and What Doesn't9 min
• Tobacco Cessation and Chronic Disease Prevention8 min
• GLP-1 Medications and the Weight Management Imperative8 min

Master the financial mechanics of self-funded plan management — IBNR reserving, budget development, cash flow management, and financial reporting.

• IBNR: The Most Important Number You're Not Tracking9 min
• Budget Development and Financial Reporting9 min
• Cash Flow Management and Funding Vehicles8 min

Explore alternative risk structures for self-funded health plans — medical captives, employer consortiums, level-funded plans, and group captives for mid-market employers.

• Medical Captives: Sharing Risk to Reduce Cost9 min
• Level-Funded Plans: The Gateway to Self-Funding9 min
• Employer Consortiums and Purchasing Coalitions8 min

Design and execute employee benefits communication strategies that drive engagement, improve health literacy, and encourage smart healthcare utilization.

• The Benefits Communication Gap8 min
• Open Enrollment Communication: Beyond the Benefits Fair9 min
• Year-Round Communication: Driving Smart Utilization8 min

Build a rigorous vendor management program — from contract negotiation and performance guarantees to claims audits, PBM audits, and vendor replacement decisions.

• Contract Negotiation: Getting the Terms You Deserve9 min
• Claims Audits and PBM Audits: Finding the Money9 min
• Performance Management and Vendor Replacement8 min

Master the self-funded plan renewal process — from pre-renewal analysis and stop-loss negotiation to plan design changes and vendor performance reviews.

• Pre-Renewal Analysis: Setting the Stage9 min
• Stop-Loss Renewal: Negotiating in a Hard Market9 min
• Plan Design Changes and Employee Communication8 min

Navigate the broker and advisor landscape for self-funded health plans — understanding compensation models, fiduciary standards, CAA disclosure requirements, and how to evaluate advisor quality.

• Broker Compensation Models: Commissions, Fees, and Conflicts9 min
• Fiduciary Advisors: The New Standard9 min
• Building the Advisory Team8 min

Execute a successful transition from fully insured to self-funded — covering the implementation timeline, vendor selection, employee communication, and first-year management.

• The Transition Decision: Timing, Readiness, and Risk9 min
• Implementation: Vendor Selection and Timeline10 min
• Employee Communication for the Transition8 min

Explore the cutting edge of self-funded health plan strategy — AI-powered analytics, direct contracting, value-based care, and the evolving regulatory landscape.

• AI and Advanced Analytics in Self-Funded Plans10 min
• Direct Contracting and Value-Based Care10 min
• The Evolving Regulatory Landscape9 min