“They Don’t Know Our Business”

“The market is rapidly changing with new players coming in led by young techy types starting TPA operations incorporating the latest AI based technology. How are you keeping up with this? I asked

ACA Premium Hikes, Expiring Subsidies, and the ICHRA Ripple Effect: What to Watch in 2026

By Justin Leader

With the enhanced ACA subsidies set to expire and insurers filing for 15–20%+ premium increases in 2026, many are bracing for what could be a massive affordability shock for middle-class families, especially those who have relied on expanded subsidies since 2021.

Cost of Obamacare Goes Down Despite Fake News Report

“Cost of Obamacare is expected to soar” headlines the reporter. Not true. Other than the usual annual rate increases we’ve experienced every year for the past 40, the cost hasn’t increased at all. In fact the opposite is true…………for the first time in living memory the cost has decreased.

Monte “Nostradamus” Jennings Declares The Future is Now

“Monte’s Ancestor? The ability to predict future trends before others do is a common trait of futurists. Monte Jennings insists the future is now and he’s here to lead it” – Molly Mulebriar

Another Pharma Mfg. Bypasses Middlemen – Costs Drop More Than 40%

We are beginning to see pharmaceutical manufacturers breaking away from supply chain middlemen (PBMs) saving consumers imbedded commissions (rebates) for savings of 40% and more. For example Novo Nordisk Direct and Lilly Direct offer certain GLP-1 drugs for $500 or less, a more than 50% price drop.

Billy The Drug Pusher

Oregon To Cap Hospital Payments?

New data from the Oregon Health Authority shows that commercial health insurance payments to hospitals have continued to climb, while prices for similar procedures varied widely across hospitals.AP file photo

Oregon Health Authority committee floats cap on commercial health insurance payments to hospitals

Cash Based Health Plan

A cash-based health plan with a RBP wrap does not require a traditional TPA nor does the plan require stop loss insurance. In lieu of stop loss insurance a risk transfer mechanism is triggered when the plan aggregate limit is breached.

Health Insurance Brokers Rejoice! There Is Life After Death So Be Happy

Will George Replace Insurance Brokers & Consultants Too?

Region I Education Service Center 3rd Annual Conference on South Padre Island

Connect with colleagues from across the state and gain insights from industry experts! at South Padre Island Convention Center.

Cliff Dwellers or Half Pregnant Tulip Lovers?

“Before we go further Mr. Prospect, let’s determine if you are a half pregnant flower lover with a passion for tulips or a cliff diver looking for adventure.”

I Want To Be A PBM When I Grow Up

The next time you hand over your Rx card and pay your $10 copay do you really care what the price is? Do you really want to know who gets paid what? That’s the beauty of todays managed care world. Middlemen are earning billions.

Proactive Risk Management Is Key To Managing Rising Health Care Costs

This illustration is on a 465 life case that has been on a Reference Based Pricing plan for over a decade. They have never had a rate increase.

The illustration breaks down the various cost components.

In this instance the plan is a Cash Pay Centric Plan with a Reference Based Pricing wrap.

Plan contributions are a sum of all costs distributed across participation tiers.

Plan contributions shown include a margin over expected claims. A plan sponsor may decided to fund less than the suggested funding rates especially if there are adequate booked reserves from the prior year.

How Americans Can Legally Buy GLP-1s from Canada: A Step-by-Step Guide

Ozempic 1 mg pen: ~$419 in Canada
Wegovy 2.4 mg: ~$499 in Canada
Mounjaro 15 mg: ~$680
Rybelsus 14 mg: ~$295

What is Insurance Risk?

We talk about $10/month plus the cost of the risk, but what does that really mean?

By Monte K. Jennings – Jul 14, 2025

Introduction

Today we are going to talk about risk. First we will define risk, then we will walk through an example of how we calculate risk in layman’s terms, and finally we will discuss what the risk means to you, your family, your wallet, and most importantly your insurance premium. We will also discuss why these things are so difficult to calculate.

We’re Taking It Back But You Can Keep The Wrapper

Constriction looms for a key segment of healthcare coverage

In anticipation of substantial enrollment declines, Affordable Care Act marketplace plans are pushing large increases in premiums for next year.

What Do Hidden Fees Really Mean in Your Health Plan? A Wake-Up Call for Employers

“Hidden fees are eating away at your health plan—just as they once ate away at retirement savings plans. But with the right tools, oversight and processes, you can uncover mismanagement, improper practices or unethical conduct—and reclaim control of your plan spend.”

The Rise of AI

“Within three to five years, we’ll see AGI systems as smart as the best humans. And in six years, artificial superintelligence smarter than all of us combined. T

The AI Copilot That Superpowers Health Benefits Navigation

SOURCE: Out Fox Health

Give your members a better experience at a lower cost with Outfox Health.
Now that’s smart………

Great Hospital, Great Prices, Great People

“How much do you charge for the operating room? I asked.

What Is The Best Cash Price For A MRI In Corpus Christi, Texas?

Joe Sixpack wanted to know where he could get the best cash price for a MRI. His employer’s group health plan pays the lowest cash price for any given service in full so Joe was pretty much incentivized to find the lowest cost.

Medical Industrial Complex Sucks More Money From New Jersey Taxpayers

“The largest recommended increase is in the Local Government (SHBP-LG) plan, where AON has called for a 36.5 percent increase in premiums. In the School Employees’ Health Benefits Program (SEHBP), AON has recommended a 29.7 percent increase. And in the State Health Benefits Program (SHBP-State), the recommended increase is 21.0 percent.”

Medical Decisions Should Be Made By Doctors, Not Insurance Companies

By Dr. Elisabeth Potter, MD

I’m sharing an actual recent peer-to-peer call that shows what physicians and patients face when trying to get a surgery approved. This call felt as absurd as it sounds.

The peer-to-peer call was to advocate for surgery to prevent and treat lymphedema for a patient with breast cancer. Her risk is high and we can perform a surgery to lower it.

The Medical Industrial Complex

“Pharmaceutical companies and chain hospitals are key healthcare corporations within the Medical Industrial complex.”

The Wild And Crazy World of Insurance

Pete Tessier knows Insurance. As the host of the Insurance Podcast, he speaks to Insurance professionals about the challenges in the business. But let’s face it – no one really thinks about Insurance unless they work in it.

The Price You Must Pay To Get On A Spreadsheet

*Image created based upon real text messages between PBM and Consultant*

By Chris Deacon

At a recent event, I mentioned something in passing: “You know, the price vendors have to pay just to get on the spreadsheet.”

The Rise of A New Class of HealthCare Navigator

By Sidney Haitoff on Linkedin

As access barriers are torn down by new payment models, modern admin infrastructure, and AI, we’ll see a new class of healthcare navigator emerge. These sherpas will help curate optimal pathways, manage alerts and alarms, translate new data models, and coordinate collaboration across service sites and delivery channels, and triage issues.

Choice Benefits

Start an ICHRA and add Choice Benefits

It’s time to turbocharge your employee benefits plan and change how you shop and administer employee benefits.

You Can’t Be Bound By A Contract You’ve Never Seen

By Chris Deacon

You can’t be bound by a contract you’ve never seen. Unless, apparently, you’re a self-funded employer.

“New Frontier” In Employee Benefits For County Employees

“For county employees, navigating healthcare can often feel like another job—long waits, rushed appointments, and unclear bills. But with this new Advanced Primary Care model, employees enjoy easy, on-site access to care, at times that work with their schedules, and a location that is convenient for them. No complicated scheduling systems or insurance red tape—just care when they need it.”

Deacon Exposes Brokerage Agreement Between National Consulting Firm & Major PBM

The Streisand Effect

Brokerage Firm Earns $7 Per Script. At a statistical average of 1.2 scripts per member per month (not per employee), that can add up to a butt load of money………..

CURATIVE INSURANCE COMPANY vs ASCENSION-SETON

“For the time being, Ascension-Seton remains non-participating in our traditional network because it charges substantially higher than market rates to provide care for Curative members.” – John Bock, Vice President of Sales

ZorroRX

ZorroRX is a health benefits program designed to make healthcare more accessible and affordable for patients while reducing costs for employers. We partner with hospital pharmacies to offer $0 copays on medications, free telehealth visits with specialized pharmacists, and dedicated concierge support.

Amazing Technology

You just got a balance bill from a hospital. “You owe us $30,000 because your insurance company underpaid us!” was the note on the bill. “Pay up or we’ll send you to collections and you will forever be labeled as a DEADBEAT!”

Eliminating Group Health Plans Could Benefit Workers

Study indicates that replacing group health plans with individual plans will benefit workers…………

CVS Caremark Drops Coverage of Popular Weight Loss Drug

SOURCE: Fox Business (READ THE LAST TWO PARAGRAPHS)

CVS Caremark, one of the three major pharmacy benefit managers (PBM) in the U.S., stopped coverage for Eli Lilly’s popular weight-loss drug Zepbound, blaming drugs like it for driving up overall plan costs.

Texas News Anchorette Goes Viral

KSAT anchor goes viral for ‘speaking the truth’ about Texas leaders

KSAT12 anchor Stephania Jimenez has gone viral after “speaking the truth” about Texas leaders and their response to the deadly flooding that has killed over 80 people in the state over the Fourth of July weekend.

More Reasons Why Employers Are Getting Out of The Health Insurance Business

“The Big Beautiful Bill, signed into law by President Trump on July 4, 2025, spans nearly 900 pages and touches numerous aspects of federal policy. Nestled within this lengthy legislation are employee benefits provisions that will require employers to navigate new rules, opportunities, and compliance requirements.” – Amundsen Davis

The TPA Network Agreement – The Wooley Mammoth in the Room

By Bill Hennessee

Question: What prevents all of the best healthcare savings solutions to be implemented in large self-insured companies?! Answer: The TPA network agreement.

Me Too Brokers

By Bill Rusteberg

It’s easy to spot a Me-Too Broker. You know the type. The kind that goes along to get along. Remember Little Johnny in second grade? He was the teacher’s favorite. Remember that? Well………..Little Johnny changed his name to John and he’s now a group health insurance broker posing as a consultant.

Billy Explains Medicaid In 4 Minutes

Bill sets the record straight on the Big Beautiful Bill.

McAllen ISD Faces $4.8M Health Insurance Shortfall

“Health insurance woes took center stage at the McAllen ISD Board Workshop on May 28, 2025, as officials revealed a projected shortfall of $4.8 million for the district’s health insurance plan.”

Say Goodbye to Scheduled Meetings: The Benefits of Impromptu Collaboration

“One of the main advantages of impromptu collaboration is its ability to foster quick thinking and adaptability. “ – Josua Evans

Centene Corporation – The Biggest Health Insurance Carrier You Never Heard Of

By Patrick Moore

5 years ago when I was building a slide deck about the biggest health insurance companies in the 🇺🇸 the named popped up. I spent my career on the group side so it was never really a company i paid attention to. They focus alot on the medicaid and the individual market under a brand called Ambetter Health.

Will Employers Replace Defined Benefit Plans with Defined Contribution Plans?

“Employers should assess employee preferences for group plans versus CHOICE arrangements, documenting decisions to demonstrate fiduciary prudence…...Employers must ensure group coverage remains comprehensive and cost-effective compared to CHOICE arrangements…… Fiduciaries may need to evaluate whether continuing group plans……….”

Frontier Direct Care

The suspect on the left is Joe Wilson. Don’t let him in the door he might sell you something. He’s that good.

Employer Built Stop Loss

SOURCE: Aegis Risk

Stop loss insurance is getting more expensive. Average rate increases for 2026 are expected to be in excess of +20%. Higher prescription drugs costs is one of the main cost drivers. However, there are alternatives for plan sponsors to consider.

Ruben Edelstein

By Bill Rusteberg

Ruben Edelstein practiced managed care in his own way. The son of immigrants, he ran a successful furniture business in South Texas. An astute businessman, he grew the business with locations throughout the Lower Rio Grande Valley in deep South Texas.

MedSave’s Simple Plan

Structuring a self-funded health plan requires positioning of more moving parts than a Swiss watch. All must sync in perfect harmony but often don’t. And the costs can mount up fast, often costing more than $100 per employee per month in administration fixed costs alone.

Commissioner’s Bulletin # B-0005-25

June 5, 2025

To: Insurance companies writing personal automobile and residential property policies in Texas

Re: 2025 HelpInsure.com price comparisons data call

The Texas Department of Insurance (TDI) issues this data call to gather information for the HelpInsure.com website. HelpInsure is a resource for Texas consumers who are shopping for personal automobile or residential property insurance. Insurance Code Section 32.102 requires that TDI provide this information. Responses for this data call are due by July 11, 2025.

There’s No Such Thing As A Million Dollar Claim

By Bill Rusteberg

A few years ago we were having a few late afternoon beers, as was customary on most business days, at the CEO’s private office in West Texas. Although I was not a “regular” since I lived many miles away, when I had occasion to visit I always looked forward with keen anticipation to the late afternoon “business meeting” that would invariably take place. It was always an enjoyable time, with much banter back and forth, with an occasional visitor or two dropping by to add to the atmosphere.

Meet George, Your New Health Insurance Broker

George is an incredibly talented health insurance broker. He writes and services more business than all the largest brokerage houses combined in days gone by.

Allstate Benefits Group Health joins Nationwide®

Peyton Manning is super excited about the news!

TRS ActiveCare 2025-2026 Benefits & Rates

Texas government health plan for pubic school employees has published 2025-2026 benefits and rates. Go here, pages 24-37 for details.

South Texas Politics – A True Story

“You are short sighted. When the new board gets in you will regret this.” – TPA

The year was 2004. The TPA was Houston based. The group was a South Texas school district located in the Lower Rio Grande Valley.

The Jacked Up World of Cost Containment

Victor Lustig

The American health care delivery system is about as jacked up as jacked up can get. Employers scramble to mitigate rising health care costs by hiring outside cost containment firms employing any number of strategies. This additional plan expense can effectively double or triple fixed costs leaving fewer budgeable dollars to pay claims.

Telemarketing Script Kills It

Attention Insurance Salesmen! Try this script and increase your sales overnight!

How Is This Legal?

How is this legal?

How Much Does An ER Visit Cost?

By Josh Nakka

Most people guess a couple thousand dollars, but the reality can be far more shocking. An ER bill can sometimes top $20,000.

Script Sourcing Third Party Vendors Save Plan Sponsors Millions In Prescription Drug Spend

PBM Sales Rep. Reacts To The News……………….

Plan sponsors seeking solutions to high cost prescription drugs must understand a single source solution is not their best bet. Lowering Rx costs is all about sourcing the right drug at the right price. It’s that simple.

How To Convert A Fake Billed Charge To A Real Price In Seconds

“Everyone knows a billed charge is bull shit. It’s like a sticker price on a new car. No one ever pays full billed charges unless they are brain dead. Leon has developed an AI tool that cuts through the bull shit” – Bill Rusteberg

Normandy Seeking P&C Agents

You read that right. Three simple steps, no premium commitment, and you’re getting appointed today.

Missing Toothbrush Found After 52 Years

Chinese man, 64, finds toothbrush he swallowed at age 12 stuck in intestine, needs surgery

The Cash Pay Revolution Continues

“Cash has more power and influence than a health insurance card with a logo” Molly Mulebriar

The Curative Zero Card has a new name: the Curative Cash Card. Why? Because it now covers even more services, and makes it even easier for members to use their $0 benefits.

Rx Flyer Found In Lonely Rural Mailbox

In a remote part of a South Central Texas county there stands a lonely mailbox, the last one on a rural route 12 miles from a city no one has ever heard of. It’s a window to a wider world of strange and amazing things……………

Carrier Ditches Traditional Group Insurance Plans To Promote ICHRA

Insurance company announces it will exit the fully-insured, self-funded and level funded market to concentrate on individual policies through Individual Coverage Health Reimbursement Arrangements (ICHRA).

“We are committed to helping employers find affordable health insurance options for their employees. We believe that one answer can be found in our individual plans and are excited to provide a solution for employers in CT through an Individual Coverage Health Reimbursement Arrangement (ICHRA).”

Mark Cuban Floats Bold Healthcare Plan: ‘Zero Premiums To Insurance Companies’ With A Cash-Pay Revolution

“This is not a new idea but a good old idea. Cuban proposes the government provide the equivalent of a $50,000 stop loss policy for all Americans – an ACA Re upgrade. Let’s do it!” – Molly Mulebriar

Federal Judge Rules Providers Can Sue To Enforce Unpaid IDR Awards

“Get your check book ready………………” – Don Pedro

Eliott Listman – Allia Group – Litigation CEO

A federal court in Connecticut ruled that providers can sue to enforce unpaid IDR awards under the No Surprises Act, rejecting insurer arguments that there’s no private right of action.

Even The Clouds Know

Picture stolen from Josua R …….

Do we still need traditional PBMs?

“It’s evidently possible to run an effective discount network without the associated bloat and misaligned incentives of a traditional PBM…..”

Bird Dogging Jilted Lovers

ICHRA administrators don’t need brokers but they pretend they do. They often play both sides, direct sales and broker introduced door opener sales.

Nobody Hates Insurers Like Doctors

By Craig Gottwals

“While hospitals and insurers are milking employers for two to six times Medicare every chance they get, doctors get the stuffing kicked from them in the insured market. “

Medicare and Social Security Go-Broke Dates Pushed Up Due To Rising Health Care Costs

Medicare is on track to be broke in eight years. If Medicare For All is implemented then it stands to reason the Medicare risk pool will benefit by the addition of younger and healthier people. Odds makers expect that to happen because it will. Medicare won’t be a risk pool of oldies anymore.

Nothing Is Forever

Government “enhanced” premium assistance for ACA plans is set to expire at the end of this year.

The ER Is Bursting at the Seams — Employers Hold the Key to Change

Employees visit ER “as a quick fix for their healthcare needs, particularly for mental health conditions.”