How do we save money without cuts?

It depends. The 100 and 250 employee marks are usually where self-funded starts to make sense.

Level-funded. Lower risk. You pay a fixed amount every month and get money back at year end if your people stay healthier than expected. Recovers 8 to 15% of the margin your carrier keeps, and you get your claims data.

Self-funded. More upside. You pay actual claims as they come in, with stop-loss insurance capping your worst year. Every dollar saved is yours. The trade is month-to-month variability.

We model both against your census before recommending either.

Reference-based pricing (RBP) prices claims against a defensible benchmark instead of a negotiated network discount, typically 15 to 30% off facility cost, with balance-bill advocacy defending the member. Cash-pay goes further: direct payment to vetted providers with no network at all, 30 to 50% off cash-paid procedures. Both work best paired with a transparent pass-through pharmacy contract (PBM) and a payment integrity audit.

Yes. Stack the levers and the curve bends negative. Steerage takes 11 to 17% off medical, a transparent pharmacy contract 15 to 25% off Rx, the risk layer 30 to 40% of the carrier spread, payment integrity 1 to 1.5% of claims recovered, and indirect spend 10 to 30%+ outside the benefits P&L entirely. Aggregate: negative trend by year two or three, and savings starting on Day 1.

A CHOICE Arrangement, previously known as an individual coverage health reimbursement arrangement (ICHRA), replaces the group plan with a fixed monthly allowance each employee uses to buy their own individual-market plan. It converts unpredictable trend into a capped budget line with no renewal volatility. It fits best when budget certainty is the top priority, or when your workforce is geographically dispersed or has wide age and family variation. The trade is network continuity and the loss of group-plan levers.

On September 3, 2026, CMS and the SBA adopted CHOICE Arrangement, short for Custom Health Option and Individual Care Expense Arrangement, as the name for this benefit. It was a rename only. The regulations, eligibility rules and affordability tests are unchanged, IRS guidance still uses ICHRA, and existing plan documents keep their current wording until your administrator or counsel updates them.

No, you don't have to wait for renewal. Cost-saving payroll bolt-ons, $0-copay pharmacy formularies, and indirect spend optimizations can be done any time of year. Insurance renegotiation can be done in the months leading up to renewal, and we can check against your last renewal any time. Waiting for the anniversary date costs a year of savings you could have had.

Fully insured is what most employers have. You pay a premium. The carrier keeps whatever it doesn't spend on claims, and you never see the split. If your people have a healthy year, the carrier keeps the difference. You also don't get your claims data, so every renewal is a number you're asked to accept without evidence.

Level-funded looks the same from the outside. Same fixed monthly payment, same predictability. But the money is accounted for separately: claims, administration, and stop-loss insurance for a bad year.

Two things change. If claims come in under expectation, that surplus comes back to you instead of to the carrier. And you get your claims data, so next year's conversation is one you can actually have.

You typically save 8 to 15% of premium, and you carry no more risk than you do today.

Possibly, and you can incentivize better outcomes with steerage, and save 10%+.

An HRA is a different question from how your plan is funded. It's about how much of the deductible your employee actually feels.

You offer a high-deductible plan, which costs you less in premium, and promise to cover part of that deductible if they need care. Those are notional dollars. You only pay if someone actually uses it, and most people don't. Your employee gets to choose the cheaper plan without fearing the deductible.

Many people confuse HRAs and HSAs. They're very different.

An HRA is your money, on your terms. You decide what it covers, it never leaves your books unless it's used, and anything unused stays with you.

An HSA is the employee's money, in their own account, funded for real. It's theirs to keep and spend as they like, even if they leave tomorrow.

Both pair with a high-deductible plan. Only one of them gives you the money back.