Risk Managers – Thought Leadership on Health Insurance

On-Exchange vs. Off-Exchange ACA Marketplace Plans

If you’re familiar with Affordable Care Act (ACA) Marketplace plans, you may already know how they work. ACA Marketplace plans are health care plans that people can buy on their own, rather than through an employer or another government-run program, like Medicare or Medicaid. But do you know the difference between an on-exchange plan and an off-exchange plan? Read on to learn which choice could be the right fit for the coverage you need.

Rip Off Artists Feed Off Clueless Plan Sponsors

By Bill Rusteberg

Somebody is getting ripped off somewhere. And it could be you.

Best Benefits Online™ Is Your New Best Friend

Best Benefits Online™ modernizes employee benefits with real choice, and zero admin complexity—all in one platform – A modern, sensible and common-sense solution for employer sponsored health plans and associations.

Texas County Seeks Fee-Based Insurance Consultant

Willacy County Seeks Insurance Consultant

Willacy County is not seeking a conventional insurance broker or another plan administrator. It wants an outside expert who can help protect and improve an existing cost-containment model, evaluate claims performance, strengthen direct provider arrangements, and support sound financial decisions.

PRAM Rx

PRAM is a licensed Insurance Underwriter and General Agent. PRAM is one of the nations leading Pharmacy Underwriters that brings over one hundred years of knowledge in underwriting and managing employee benefits for not only Independent Companies, but Associations, Franchises and Trusts.

Port of Corpus Christi Seeks Broker of Record

The Port of Corpus Christi Authority is soliciting proposals from qualified insurance brokers to provide insurance brokerage and risk management consulting services, including insurance placement, risk exposure analysis, claims assistance, and ongoing advisory services for the Port’s insurance and risk management programs.

Check It Out, Urgent Care Is Fun

Ever been to an urgent care? Check it out, it’s fun. There’s no ego in an urgent care.

The Legal Wave: Why Health Plans Are The Next ERISA Battleground

Plan sponsor pleads for mercy…….”I didn’t know my broker made us broker!”

Passive plan management is no longer an option plan sponsors can afford…………

Weslaco ISD Believes The More The Merrier…………..

The Weslaco Independent School District believes having three insurance agents sharing the spoils is better than having just one, so they hired four…………..

Brokers: Learn More About ZERO FIRST

We shared Curative’s new plan design, Zero First, with you last week. Friday’s your chance to get additional details, straight from our CEO, Fred Turner.

Look Up Where Your Generic Prescription Drugs Were Made

SOURCE: ProPublica

The FDA won’t tell Americans where their generic drugs are made, so ProPublica did it instead. Use information on your prescription label to locate the factory and see inspection reports.

Plan Sponsors Suffer From Learned Helplessness

“Learned helplessness occurs when a person who has experienced repeated challenges comes to believe they have no control over their situation. They then give up trying to make changes and accept their fate” – Seligman & Maier

Section 125 Cafeteria Plan Penalties: What Happens When a Plan Fails

SOURCE: Section 125 Cafeteria Plan Penalties for Employers

Quick Answer (as of 2026): The IRS does not charge one flat fine for a Section 125 cafeteria plan failure. The penalty is that the plan stops being a cafeteria plan, so every pre-tax deduction becomes taxable wages. The employer then owes back FICA and income tax withholding, plus IRS failure-to-deposit penalties of 2% to 15% and interest.

Aldeen’s Sunday Morning Bathroom Read

By Doug Aldeen

The Kaiser Foundation recently reported that in Texas nearly half of nonprofit hospitals say they will bill patients before screening them for financial aid. And most hospitals will not offer refunds to patients who pay and are eventually found to qualify for free care.

All Self-Funded Health Plans Must Do This March 2027

Government says if you’re self-funded you have to do this in 2027 or face punishment if you don’t.

Medicare GLP-1 Bridge

The Medicare GLP-1 Bridge is a short-term demonstration run by CMS that will provide eligible Medicare Part D beneficiaries with access to certain GLP-1 drugs between July 1, 2026, and December 31, 2027.

Congress Wants to Eliminate IDR

“I knew it was not going to go well, but I didn’t know it was going to be this bad.”

American Tries Healthcare in China — He Couldn’t Believe the Cost

Americans are increasingly choosing healthcare in China for advanced medical treatment. See how technology is changing care.

TotalRx Is A Free Service

Never pay retail for any FDA approved prescription with TotalRx.ai !

Willacy County Seeks Insurance Consultant

The Willacy County Health Plan risk pool is a community-based plan. Participating entities join through an interlocal purchasing agreement and share underwriting losses/profits and administrative expenses.

HR Conducts Short & Pithy Open Enrollment Meeting

HR DIRECTOR: Good Morning Children! Welcome to Open Enrollment. Everyone should have a copy of the Plan Document in front of them. Let’s get started!

McAllen ISD Has A $9,000,000 – $12,000,000 Headache

SOURCE: McAllen ISD Board Meeting October 20, 2026

At their 20 October 2026 board meeting trustees of the McAllen Independent School District will be reminded they have a $9,000,000 to $12,000,000 health insurance problem.

The good news is they should feel much better knowing the Brownsville Independent School District just down the road has a $28,000,000 health insurance headache.

THE BROKER PAY FILES | EPISODE 1

“In a Blue Cross and Blue Shield of Texas proposal for the CITY OF GALVESTON‘s 2025 health plan, under “Commissions,” Gallagher was listed to receive $2.25 for EACH net paid pharmacy claim…….Now look at Austin Independent School District ……………”

ZERO FIRST HEALTH PLAN

Over the past year, brokers kept telling us the same thing: clients love Curative, but price is often the deciding factor. So, we built Zero First. A Curative plan that stays true to our mission of $0 access to care at a more competitive price point.

Get Sick To Get Paid

When a provider bills less than the benefit the plan member receives a check for the difference………………..

Knowing When To Say Goodbye

Albert knew when it was time to say goodbye……………………

Were The Cats On The Ship?

By Marc Gravely

In 1780, a London broker told a client his claim came down to one question. Were there cats on the ship?

Another Win For Curative Insurance Company

Bexar Central Appraisal District trustees awarded a one-year contract to Curative Insurance Company at their October 12 board meeting after a 37 second pithy yet compelling presentation by the district’s insurance consultant.

More Large Groups Adopt ICHRA

“Except the fastest-growing segment is employers with 1,000+ employees. Adoption there is up 178%. These aren’t businesses with no benefits history. These are companies that ran full group plans for years and decided a defined-contribution individual model is the better buy.”

OPEN LETTER TO BISD TRUSTEES

By Bill Rusteberg

You will not hear this from any insurance broker or consultant. But it needs to be said………..

Digital Therapeutics: When Apps Become Medicine

“As we transition into an era defined by patient-centric care, the integration of digital tools into traditional clinical pathways is no longer a futuristic concept but a tangible reality.”

Algorithmic Underwriting: The Future of Payer Ecosystems

“In an era where consumers expect instantaneous service, the traditional underwriting turnaround time—often spanning weeks—is no longer competitive. Algorithmic underwriting addresses this bottleneck by automating complex approval workflows, allowing for near-instantaneous decision-making.”

West Texas Hospital Administrator VS RBP Rable Rouser

Lubbock Texas is a two-hospital town supported by managed care plans including Medicare and Medicaid. Commercial insurance plans, 100% of which are managed care plans too, subsidize Medicare and Medicaid patient because hospitals say they do.

Legislation Introduced To Fix The No Surprises Act Arbitration Process

When You Can’t Get It Right The First Time….

“The arbitration process (IDR) is clearly not working. A few bad actors—largely backed by private equity—are gaming the system……………..”

Why Your Group Health Plan Feels Like a Group Project That Never Ends (And How ICHRA Fixes It)

By Michael Reagan, CBPA – October 10, 2026

Remember when health benefits were simple? You picked a carrier, hoped the renewal didn’t make you cry, and spent the rest of the year explaining why Brenda in accounting still can’t find an in-network dermatologist. Those days are mostly gone.

Another School District Health Plan Serving 100 Districts Bites The Dust……….

By Allison Bell, BenefitsPro, 10/2/2026

Idaho school districts used the trust to provide medical, dental and vision benefits.
The trust served 16,500 school district employees and dependents.
The trust was not backed by the state guaranty fund.

PPOs Double Your Pleasure, Double Your Fun….

“Double your pleasure, double your fun with double mint, double mint, double mint gum.”

RiskManagers.us Business Statement

RiskManagers.us is a specialty company in the benefits market that, while not an insurance company, works directly with health entities, medical providers, and businesses to identify and develop cost effective benefits packages, emphasizing transparency and fairness in direct reimbursement compensation methods.

HR Executives Face Unprecedented Personal Liability

HR Director Reacts After Served With Lawsuit

“A perfect storm of Supreme Court decisions, aggressive litigation and emerging technologies is exposing HR executives to unprecedented legal liability, even for decisions made by their outsourced partners.”

Risk Tolerance – The Fundamental Basis of Goal Setting

“The problem I see with most health insurance consultants is almost all pre-determine a client’s tolerance for risk before determining where the risk tolerance actually lies.”

Brownsville ISD Believes In Magic

Live Stream | Brownsville ISD – Start 1:36 through 1:55

At their October 6, 2026 board meeting the Brownsville Independent School District trustees, facing a $28,000,000 deficit on their self-funded health plan, approved a one-year extension to make it worse.

Public Filings Expose Voluntary Benefits Commissions to ERISA Litigation Risk

“Plaintiffs are borrowing legal theories long used in retirement-plan fee cases, including breaches of prudence and loyalty, failure to monitor and prohibited transactions….”

Big Pharma Sues Over Lower Drug Prices

Reuters

By Michael Erman

Oct 7 (Reuters) – The pharmaceutical industry’s top lobby group ⁠on ⁠Wednesday sued to invalidate one piece ⁠of the Trump administration’s efforts to benchmark US drug prices to lower costs overseas in the Medicare health insurance program, arguing that it is an illegal overreach by the US government.

UHC Golden Rule Commission Bonus Opportunity

If you are a consumer, don’t read this top-secret insurance posting……………

Holy Voluntary Benefits Batman

By Trey Shields

Aon rained all over Macy’s parade, allegedly. Snagging $13.2M in commissions out of just $36.1M in premiums?

Carvan Coverage LLC

Micromanaging Insurance Committees

“When you micromanage, you’re telling your team you don’t trust them.” – Simon Sinek

Pharma USA 2027

North America’s largest cross-functional pharma gathering………..

Following the launch of Reuters Events Pharma USA 2027, we’re now looking to recognize the innovators and future leaders shaping the next chapter of Pharma.

Insurer of Last Resort

“No problem Joe, I’ll make a call for you”

The obituary is fake. George Parr, The Insurer of Last Resort, is alive and well……….

How Medicare Premiums Are Calculated and Set

Over 20% of the U.S. population are Medicare beneficiaries. Medicare is described as health insurance but it’s not. It’s a government tax-based pool of money used to pay for the health care needs of mostly old people……….old people who have paid into the pool all their working lives and most if not all continue to pay whether they use it or not. What they pay is called premiums.

Trump to Give $90 to Senior Citizens for Medicare Premiums

By Kaanita Iyer, Tami Luhby, CNN – October 3, 2026 – Source: CNN

President Donald Trump said late Friday he will give around 20 million senior citizens $90 each to help pay for their Medicare Part B premiums, marking his latest effort to dole out funds to certain Americans weeks before the midterm elections.

Government Approves Reference Based Pricing Plans for 2028

“Health plans that aren’t built around provider networks will be allowed on the ACA individual marketplace beginning in 2028, marking a structural change to a system that has operated exclusively on network-based models since the ACA launched more than a decade ago.”

Network Plans Save Money

Nothing complicated about it. Network plans improve mental health and save money at the same time………

By Bill Rusteberg

Everyone loves their health insurance plan. High deductibles, ever higher out-of-pocket costs, and narrow networks encourage patients to avoid the stress and expense of accessing care when needs arise. Maintaining mental health has never been easier.

Dry Cleaning Insurance

New niche market for brokers seeking relevancy in the dry-cleaning business.

Tips for Fee-For-Service Doctors

Now that there are no taxes on tips, more doctors are taking notice. What better way to wean off the fee-for-service teat than to work for tips.

Former Hospital Administrator Does A Benedict Arnold

Former hospital administrator moves to the other side of the table, using his insider knowledge to help plan sponsors manage their healthcare dollars wisely……

Rx Prices – You Can’t Fix What You Don’t See, You Don’t Know What You Don’t Know………..

“You can’t fix what you don’t see. You don’t know what you don’t know. We see opportunities others miss. We do what others don’t. Winning together is our goal” – Bill Rusteberg

By Mike McLain

The drug costs $133 a year at cash price. The JPMorgan plan paid $74,751…….1 employee. 1 generic drug. 12 fills.

RiskManagers Business Statement

County Raises Sales Tax To Support Health Care Needs of 700,000 Residents

Sales tax increase expected to raise $1 billion annually to benefit 700,000 residents and punish hospital ERs.

The Math Behind Stop Loss Renewals

By CJ Jordan

Your high stop loss renewal is a function of a bad math problem. The math doesn’t math. Let me explain.

Brownsville ISD To Renew with UnitedHealth

Long drawn-out proposal process is finally over after endless meetings and vendor presentations……………….

At their upcoming October 6, 2026 regular Board meeting district trustees will consider an action item to renew third party administrative services for their self-funded health plan with United Healthcare of Houston, TX.

Blue Cross Blue Shield: AI-Assisted Medical Coding Added $1 Billion in Hospital Costs

Hospitals’ growing use of AI to assign medical billing codes contributed close to $1 billion in extra costs for Blue Cross Blue Shield health plans between 2023 and 2025, according to a new analysis from the insurer’s trade association. 70 percent of the additional cost involved additional diagnoses that did not change patients’ actual care, according to the insurer, which describes the situation as a “clear disconnect between coding and treatment.”

The Stop-Loss Market is Hung Over

By Craig Gottwals – Attorney & RBP Expert – October 1, 2026

Higher claim severity, tighter underwriting, and strained carrier economics are driving 2027 renewals.

In 23 years of installing self-funded health plans, I cannot remember a medical stop-loss market quite as constipated as this one.

The Neighbors Came First: What a Century of European Health Cooperatives Teaches American Policymakers and Investors

By Dave Chase – September 28, 2026

In 1899, sixty members of the Catholic Workers’ Association in Switzerland promised to help carry each other’s costs when illness or accident struck. That promise became CSS, which now insures about 1.7 million people, almost one in five Swiss, and still belongs to the association that grew from its founders.

Mark Cuban: Why US Hospitals ‘Don’t Know Their Costs’

By: Alan Condon – September 1, 2026

Mark Cuban argues the fundamental problem in U.S. healthcare is not whether the system is run by the public sector or the private sector. It is that hospitals do not know what their own services cost.

Dr. Oz Pitches CHOICE Health Plans

Choice Is An Everyday Event…………………………..

“For too long, employers and workers have been stuck with a one-size-fits-all approach to health benefits,” Dr. Oz said in a news release. “CHOICE changes that by giving businesses greater flexibility and giving employees more control over the coverage that works for them.”

Texas System Sets World Record As Largest Medical Center

By: Paige Twenter – September 21, 2026

Houston’s Texas Medical Center has been formally recognized as the world’s largest medical complex, a title the 1,345-acre campus has long claimed for itself.

Invertebrates Are Status Quo’s Best Friend

“Demonstrated reluctance to consider suggested strategies indicates a growing tendency towards static risk management which is contrary to proper oversight. We bring no value in exchange for the fees you pay us when the status quo isn’t continuously challenged with evolving strategies and a wiliness to act when it’s in the best interests of the plan and plan members no matter how hard change may be.”

Willacy County Did What!

In August the Willacy County Health Plan awarded TPA services to 90 Degree Benefits for an October 2026 effective date after a competitive Request for Proposal process. Now we learn another TPA has also been awarded the contract ostensively for the same effective date.

Parasitic Disease Epidemic Decimates Working Americans

By Taryn Shipley, MBA, CSSBB

Insurance companies are a parasite on the US healthcare system. Look at how much of Epic exists just to navigate insurance.

Cutting Out PPO Middleman

More plan sponsors are beginning to understand PPOs bring no value to health care financing, only higher costs turbocharged by annual escalator clauses……

How AI Is Already Changing Health Plan Administration

By Dan Thompson – SOURCE: HVBA

For decades, open enrollment has followed the same script: a flood of PDFs, a confusing comparison chart, either in a printed guidebook (that had multiple versions) or on a digital handbook that is emailed out to employees. This is coupled with a benefits team inbox buried in questions, and employees clicking through choices they only half understand — maybe.

Angle Health – A $2.7 Billion Insurance Company You’ve Never Heard Of…..

Bet you’ve never heard of Angle Health. It’s different. Imagine getting a firm quote in minutes rather than waiting days and weeks to get quasi-firm quotes from legacy brokers and stop loss carriers.

Have PPO Networks Perpetrated The Greatest Heist In American History?

“Understanding the cost of health care is directly related to what we agree to pay, more and more employers are questioning managed care contracts upon which their health care costs are based. Many are discovering the truth for the first time.”- Bill Rusteberg

Oklahoma Insurance Commissioner Sounds AI-insurance Fraud Alarm

By Maura Keller

As artificial intelligence becomes more accessible, it also creates new opportunities for criminals to commit increasingly sophisticated insurance fraud, according to the Oklahoma Insurance Department and Insurance Commissioner Glen Mulready.