
“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
Continue reading “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
Continue reading “They Don’t Know Our Business”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.
Continue reading ACA Premium Hikes, Expiring Subsidies, and the ICHRA Ripple Effect: What to Watch in 2026“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.
Continue reading Cost of Obamacare Goes Down Despite Fake News Report“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
Continue reading Monte “Nostradamus” Jennings Declares The Future is NowWe 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.
Continue reading Another Pharma Mfg. Bypasses Middlemen – Costs Drop More Than 40%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
Continue reading Oregon To Cap Hospital Payments?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.
Continue reading Cash Based Health PlanWill George Replace Insurance Brokers & Consultants Too?
Continue reading Health Insurance Brokers Rejoice! There Is Life After Death So Be HappyConnect with colleagues from across the state and gain insights from industry experts! at South Padre Island Convention Center.
Continue reading Region I Education Service Center 3rd Annual Conference on South Padre Island“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.”
Continue reading Cliff Dwellers or Half Pregnant Tulip Lovers?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.
Continue reading I Want To Be A PBM When I Grow UpThis 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.
Continue reading Proactive Risk Management Is Key To Managing Rising Health Care CostsWe talk about $10/month plus the cost of the risk, but what does that really mean?
By Monte K. Jennings – Jul 14, 2025
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.
Continue reading What is Insurance Risk?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.
Continue reading We’re Taking It Back But You Can Keep The Wrapper“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.”
Continue reading What Do Hidden Fees Really Mean in Your Health Plan? A Wake-Up Call for Employers“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
Continue reading The Rise of AISOURCE: Out Fox Health
Give your members a better experience at a lower cost with Outfox Health.
Now that’s smart………
“How much do you charge for the operating room? I asked.
Continue reading Great Hospital, Great Prices, Great PeopleJoe 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.
Continue reading What Is The Best Cash Price For A MRI In Corpus Christi, Texas?“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.”
Continue reading Medical Industrial Complex Sucks More Money From New Jersey TaxpayersBy 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.
Continue reading Medical Decisions Should Be Made By Doctors, Not Insurance Companies“Pharmaceutical companies and chain hospitals are key healthcare corporations within the Medical Industrial complex.”
Continue reading The Medical Industrial ComplexPete 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.
Continue reading The Wild And Crazy World of Insurance*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.”
Continue reading The Price You Must Pay To Get On A SpreadsheetBy 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.
Continue reading The Rise of A New Class of HealthCare NavigatorIt’s time to turbocharge your employee benefits plan and change how you shop and administer employee benefits.
Continue reading Choice BenefitsBy Chris Deacon
You can’t be bound by a contract you’ve never seen. Unless, apparently, you’re a self-funded employer.
Continue reading You Can’t Be Bound By A Contract You’ve Never Seen“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.”
Continue reading “New Frontier” In Employee Benefits For County EmployeesBrokerage 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………..
Continue reading Deacon Exposes Brokerage Agreement Between National Consulting Firm & Major PBM“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
Continue reading CURATIVE INSURANCE COMPANY vs ASCENSION-SETONZorroRX 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.
Continue reading ZorroRXYou 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!”
Continue reading Amazing TechnologyStudy indicates that replacing group health plans with individual plans will benefit workers…………
Continue reading Eliminating Group Health Plans Could Benefit WorkersSOURCE: 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.
Continue reading CVS Caremark Drops Coverage of Popular Weight Loss DrugKSAT 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.
Continue reading Texas News Anchorette Goes Viral“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
Continue reading More Reasons Why Employers Are Getting Out of The Health Insurance BusinessBy 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.
Continue reading The TPA Network Agreement – The Wooley Mammoth in the RoomBy 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.
Continue reading Me Too BrokersBill sets the record straight on the Big Beautiful Bill.
Continue reading Billy Explains Medicaid In 4 Minutes“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.”
Continue reading McAllen ISD Faces $4.8M Health Insurance Shortfall“One of the main advantages of impromptu collaboration is its ability to foster quick thinking and adaptability. “ – Josua Evans
Continue reading Say Goodbye to Scheduled Meetings: The Benefits of Impromptu CollaborationBy 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.
Continue reading Centene Corporation – The Biggest Health Insurance Carrier You Never Heard Of“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……….”
Continue reading Will Employers Replace Defined Benefit Plans with Defined Contribution Plans?The suspect on the left is Joe Wilson. Don’t let him in the door he might sell you something. He’s that good.
Continue reading Frontier Direct CareSOURCE: 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.
Continue reading Employer Built Stop LossBy 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.
Continue reading Ruben EdelsteinStructuring 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.
Continue reading MedSave’s Simple PlanJune 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.
Continue reading Commissioner’s Bulletin # B-0005-25By 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.
Continue reading There’s No Such Thing As A Million Dollar ClaimGeorge is an incredibly talented health insurance broker. He writes and services more business than all the largest brokerage houses combined in days gone by.
Continue reading Meet George, Your New Health Insurance BrokerPeyton Manning is super excited about the news!
Continue reading Allstate Benefits Group Health joins Nationwide®Texas government health plan for pubic school employees has published 2025-2026 benefits and rates. Go here, pages 24-37 for details.
Continue reading TRS ActiveCare 2025-2026 Benefits & Rates“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.
Continue reading South Texas Politics – A True StoryVictor 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.
Continue reading The Jacked Up World of Cost ContainmentAttention Insurance Salesmen! Try this script and increase your sales overnight!
Continue reading Telemarketing Script Kills ItBy 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.
Continue reading How Much Does An ER Visit Cost?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.
Continue reading Script Sourcing Third Party Vendors Save Plan Sponsors Millions In Prescription Drug Spend“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
Continue reading How To Convert A Fake Billed Charge To A Real Price In SecondsYou read that right. Three simple steps, no premium commitment, and you’re getting appointed today.
Continue reading Normandy Seeking P&C AgentsChinese man, 64, finds toothbrush he swallowed at age 12 stuck in intestine, needs surgery
Continue reading Missing Toothbrush Found After 52 Years“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.
Continue reading The Cash Pay Revolution ContinuesIn 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……………
Continue reading Rx Flyer Found In Lonely Rural MailboxInsurance 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).”
Continue reading Carrier Ditches Traditional Group Insurance Plans To Promote ICHRA“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
Continue reading Mark Cuban Floats Bold Healthcare Plan: ‘Zero Premiums To Insurance Companies’ With A Cash-Pay Revolution“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.
Continue reading Federal Judge Rules Providers Can Sue To Enforce Unpaid IDR Awards“It’s evidently possible to run an effective discount network without the associated bloat and misaligned incentives of a traditional PBM…..”
Continue reading Do we still need traditional PBMs?ICHRA administrators don’t need brokers but they pretend they do. They often play both sides, direct sales and broker introduced door opener sales.
Continue reading Bird Dogging Jilted LoversBy 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. “
Continue reading Nobody Hates Insurers Like DoctorsMedicare 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.
Continue reading Medicare and Social Security Go-Broke Dates Pushed Up Due To Rising Health Care CostsGovernment “enhanced” premium assistance for ACA plans is set to expire at the end of this year.
Continue reading Nothing Is ForeverEmployees visit ER “as a quick fix for their healthcare needs, particularly for mental health conditions.”
Continue reading The ER Is Bursting at the Seams — Employers Hold the Key to Change