Helping employers stop overpaying for healthcare. Self-funded and captive health plans. Health Rosetta Advanced Advisor. NABIP Self Funded Certified.
Wichita Falls, TX
Joined October 2026
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A lot of employers have never read their broker's compensation disclosure. Under the CAA, your health plan's broker has to disclose direct and indirect pay in writing. Read the indirect part, the bonuses and fees from carriers and vendors. If it's vague or missing, ask why.
Texans on Marketplace plans, open every letter and take every call from your insurer this fall. CMS has been dropping people who didn't answer verification requests within 30 days, and getting reinstated can take weeks. A five minute phone call now is a lot easier than that.
Myth: self-funding only makes sense for big employers. Reality: smaller groups do it too, with stop-loss or a captive behind them. What matters more is whether you can stomach a bad claims month and want to see your data. Employers, what's held you back?
Simple question for any employer: does anyone advising you on your pharmacy benefit get paid by the PBM? Referral fees, bonuses, marketing money. A lot of that is legal. It should still be disclosed in writing, in dollars, before you sign. If nobody's offered that, ask.
If your employees are on an HSA plan, they're probably paying full price for maintenance meds until they hit the deductible. It doesn't have to work that way. Since 2019 the IRS has let HSA-qualified plans cover a list of chronic condition drugs before the deductible... things like blood pressure meds, statins, and insulin. A lot of employers never turned it on. Worth asking about before your 2027 plan locks.
A pharmacist's story about a PBM pushing a patient to mail order, after the patient said no, is near 180K views today. If you're an employer, that can be your plan doing it. Your PBM contract decides whether mail order is required, whether members can be switched without their consent, and whether the PBM owns the mail order pharmacy it's steering people to. Ask whoever manages your plan to show you those sections.
Myth: a nonprofit hospital checks whether you qualify for financial aid before it sends a bill. Reality: nearly half of Texas nonprofit hospitals say they bill first. HR folks, do your employees know to ask for financial assistance before paying a big hospital bill?
Open enrollment for 2027 starts Nov 1. If you dropped marketplace coverage this year because of the price, run the numbers again before you assume you're priced out. Plans, subsidies, and your income all change. A licensed agent can do that with you at no cost... a lot of people never ask.
Individual market enrollment — composed primarily of ACA Marketplace coverage as well as off-exchange coverage — fell 18% between June 2025 and June 2026, suggesting Marketplace losses are continuing.
New KFF analysis: on.kff.org/3U3WgCK
ALT Chart shows the annual change in second-quarter individual market enrollment, 2015-2026. Individual Market Enrollment Declined by 18% Since June 2025.
City health plans usually go broke slowly. Claims outgrow the budget and the reserve covers the gap until it can't. The fixes I like best are direct primary care and hospital contracts paid at a set percentage of Medicare. Both take a council willing to try something new.
Twelve independent pharmacies in Arkansas sued Express Scripts last month. They allege it paid them below what the drugs cost about 48,300 times between August 2025 and March 2026. Arkansas law says a PBM can't reimburse a pharmacy below NADAC.
If you run a self-funded plan, this is your issue too. Your PBM sets what the pharmacy gets paid and what you get billed, and those can be two different numbers. Ask for both on every claim. healthcaredive.com/news/expr…
Hot take: when a carrier and a hospital system fight over a contract, self-funded employers shouldn't be sitting in the stands. It's your claims money they're negotiating over, and you usually find out from a letter to your employees. Should employers have a seat at that table?
Open enrollment starts Nov 1, and a lot of people are about to pick a health plan by premium alone. Look at the out-of-pocket max, the network, and whether your doctors and prescriptions are actually covered. A cheaper plan with a big deductible can cost you a lot more the first time you need surgery... unless you know where the cash-price options are. If you're in Texas and want a second set of eyes on your options, send me a message.
Nice quarter for shareholders. For an employer, the better question is how much of your own plan spend landed inside that same family of companies. If your carrier, PBM, and clinics all roll up to one parent, ask in writing for every dollar your plan paid to an affiliate last year.
UnitedHealth Group reported third-quarter net income of $4.11 billion, or $4.56 a share. That compared with net income of $2.35 billion, or $2.59 a share, a year earlier. on.wsj.com/47ib9nW
A school district just watched its employee health fund go from a $57M surplus to a $97M deficit in five years. GLP-1 spending went from $34M to $80M in just two of those years. This is coming for every employer plan. Fully insured groups will feel it in the renewal without ever seeing the line item.
If you're self-funded, at least you get to decide. Coverage criteria, a lifestyle or primary care program tied to the Rx, and what your PBM is really netting on rebates. That decision belongs in your plan document, not in a carrier's rate filing. xitter.cf/MDBayNews/status/21098…
🚨 MONTGOMERY COUNTY, MD: MCPS HEALTH CARE DEFICIT BALLOONS TO $97 MILLION — TAXPAYERS COULD BE ASKED TO COVER THE SHORTFALL.
Montgomery County Public Schools is facing a growing financial crisis as its employee and retiree health care fund sinks deeper into the red.
According to Montgomery Perspective’s Adam Pagnucco, the deficit has increased from $58 MILLION last year to $97 MILLION in FY2026.
THE NUMBERS:
▪️ $57 MILLION SURPLUS: MCPS’s health benefits fund had a positive balance in FY2021.
▪️ $97 MILLION DEFICIT: By FY2026, the fund had fallen $154 million from its FY2021 position.
▪️ $34 MILLION: Spending on GLP-1 medications for diabetes and weight loss in FY2024.
▪️ $64 MILLION: GLP-1 spending in FY2025.
▪️ $80 MILLION: GLP-1 spending in FY2026.
▪️ OVER $100 MILLION: Projected GLP-1 spending for FY2027.
▪️ $40 MILLION: Estimated annual savings if MCPS stopped covering GLP-1 medications specifically for obesity, according to district staff.
▪️ $10 MILLION: Additional annual revenue expected from shifting two percentage points of health care costs to employees.
The school system has relied on temporary funding transfers to cover rising expenses, but those measures have not resolved the underlying imbalance.
Now MCPS faces three difficult options:
1. Redirect funding from other school programs and positions.
2. Increase employee contributions or reduce benefits.
3. Seek additional taxpayer funding.
The growing deficit comes after hundreds of school positions were eliminated and amid difficult labor negotiations.
The $97 million figure represents the health benefits fund’s negative balance, not the school system’s overall operating deficit.
The accountability question: How did MCPS go from a $57 million health care surplus to a $97 million deficit in five years, and who will ultimately pay to close the gap?
SOURCES: Montgomery Perspective, Adam Pagnucco, October 12, 2026; MCPS Board of Education Fiscal Management Committee, September 15, 2026.
