Self-funded employers, TPAs, and brokers: who to call and what to put in front of them

Which local employers can sign a direct contract at all?

Only the ones paying claims out of their own money. An employer that buys an insured plan bought a carrier's network with it, and cannot add you to that network or set what the plan pays. A self-funded employer sets its own terms, and that is what makes a direct arrangement possible in the first place.

Self-funding is common and it is size-skewed. KFF's 2024 Employer Health Benefits Survey puts 63 percent of covered workers in self-funded plans, splitting to 20 percent of covered workers at small firms and 79 percent at large firms 1Ref 1KFF (2024).2024 Employer Health Benefits Survey — Section 10: Plan Funding.Calibrating which local employers are plausible direct-contract targets: the survey's 63 percent of covered workers in self-funded plans overall, and the 20 percent small-firm versus 79 percent large-firm split, presented as survey estimates.. Those are survey figures and they say nothing about your county. What they tell you is where to spend the time: the locally headquartered manufacturer, hospital system, school district or municipality, and not the storefront businesses on the same block.

No published rule sets the headcount at which an employer switches to paying its own claims. Brokers carry conventions about it, the conventions differ by market, and a number quoted to you is a local habit.

So the first question about every target on your list is who writes the check when a claim comes in.

Find the self-funded employers near you, and the administrator behind each one

Public filings will tell you. A group health plan large enough to file a full Form 5500 annual report files Schedule C with it, and Schedule C is the service provider schedule: it names who works for the plan and what they were paid, which is where the plan's administrator and its broker appear 2Ref 2Employee Benefits Security Administration, U.S. Department of Labor (2026).§ 2520.103-1 Contents of the annual report.That a covered plan's Form 5500 annual report includes Schedule C, the service provider schedule, which is how a practice identifies a self-funded employer's administrator, broker and stop-loss carrier from the public record.. The form itself records how benefits are funded, and a plan paying benefits from the employer's general assets rather than through insurance is paying its own claims. Those filings are public and searchable by employer name.

But the trail stops at a size. A welfare benefit plan covering fewer than 100 participants at the start of the plan year can be exempt from filing an annual report at all, so long as benefits are paid from the employer's general assets or through insurance premiums the employer pays directly 3Ref 3Employee Benefits Security Administration, U.S. Department of Labor (2026).§ 2520.104-20 Limited exemption for certain small welfare plans.The fewer-than-100-participant exemption from filing an annual report, which is why the Form 5500 method surfaces mid-size employers and up and leaves the smallest self-funded employers with no public filing to search.. The smallest self-funded employers in a market may leave nothing public to read, which is why this method surfaces mid-size employers and up.

Work from the filing outward. The plan name gives you the employer, and Schedule C gives you the broker alongside the third-party administrator, the party that will process whatever you agree to. Walking into a first conversation already holding those two names changes what you can propose, because the mechanics of paying you run through them.

Read what the plan already pays before you name a price

The plan publishes its prices and you can read them without asking anyone. Since plan years beginning in 2022, group health plans and issuers, other than plans grandfathered under the Affordable Care Act, have had to post three machine-readable files of their own pricing: in-network rates, out-of-network allowed amounts, and prescription drug prices. The rule requires them to be available to any person free of charge and without conditions, and updated monthly 4Ref 4Internal Revenue Service, Employee Benefits Security Administration (U.S. Dept. of Labor), and Centers for Medicare & Medicaid Services (HHS) (2026).§ 147.212 Transparency in coverage—requirements for public disclosure.The three machine-readable files of negotiated pricing, the free-and-without-conditions public access requirement and the monthly update cadence, plus the out-of-network file's allowed amounts and billed charges as the benchmark for a direct price..

The out-of-network file is the one to open first if your practice would be seen out of network. It carries the plan's unique out-of-network allowed amounts and billed charges, so what you are reading is what the plan allowed and what it was billed, on the services you are about to price 4Ref 4Internal Revenue Service, Employee Benefits Security Administration (U.S. Dept. of Labor), and Centers for Medicare & Medicaid Services (HHS) (2026).§ 147.212 Transparency in coverage—requirements for public disclosure.The three machine-readable files of negotiated pricing, the free-and-without-conditions public access requirement and the monthly update cadence, plus the out-of-network file's allowed amounts and billed charges as the benchmark for a direct price..

These files are built for software and they are large. The workable route is to find the plan's or the administrator's public transparency link, take the file covering your service area, and have someone pull the handful of codes you bill. A practice with nobody to do that can ask the broker for the plan's paid amounts on those codes instead, and the fact that the same numbers are already public makes the ask an ordinary one.

Who to call, and why they can take the call

Call whoever carries budget responsibility for the health plan, and the broker of record who advises them. No statute assigns sign-off to a title, so it varies by company: at some employers the benefits director owns the decision, at others the CFO or the owner does. The broker is seldom the decision-maker and is nearly always the gatekeeper, so plan on both conversations.

The person who runs the plan has a legal reason to hear a lower price out. ERISA's fiduciary provision, 29 U.S.C. § 1104, requires a plan fiduciary to act solely in the interest of participants and beneficiaries, for the exclusive purpose of providing benefits and defraying reasonable expenses of administering the plan 5Ref 5Office of the Law Revision Counsel, U.S. House of Representatives (2024).29 U.S.C. § 1104 — Fiduciary duties.That whoever administers a self-funded employer's plan is an ERISA fiduciary bound to act solely in participants' interest and to defray only reasonable plan expenses, the standing reason a benefits decision-maker weighs a lower-cost direct proposal.. Nothing in that obliges anyone to buy from you. It does mean a credible proposal to spend less on the same care lands on someone with a duty to weigh it.

Their advisers already disclose what they cost. Since the Consolidated Appropriations Act of 2021, a covered service provider to a group health plan, a category that takes in the administrator, the broker and the consultant, has had to describe its own compensation to the plan in writing once it reasonably expects to receive $1,000 or more from the arrangement, a floor Congress wrote to adjust for inflation 6Ref 6Office of the Law Revision Counsel, U.S. House of Representatives (2024).29 U.S.C. § 1108(b)(2)(B) — Enumeration of transactions exempted from section 1106 prohibitions.The Consolidated Appropriations Act of 2021 requirement that a covered service provider to a group health plan disclose its own compensation in writing once it reasonably expects $1,000 or more, an inflation-indexed floor, as context for why a plan sponsor reads a transparent price as ordinary.. A plan sponsor reading your page is used to seeing a price with the arrangement attached. Send it in that form.

What to put in front of them

One page, and five lines on it: what services you are offering, the price for each, how the plan pays and by when, what access the employer can hold you to, and the term. Put the plan's own paid amounts for the same services beside your price and let the comparison sit there without commentary.

Pricing is where the public record runs out. No regulator or public dataset sets out typical structures for these deals or typical savings against an insured baseline, so treat a savings figure in a vendor's pitch as marketing. What you can stand behind is arithmetic you did yourself: your price times the volume you expect, against your own cost of delivering the hours, with the plan's paid amounts printed alongside.

A contract that lands changes the week it lands in. Work arrives in blocks and can fill a schedule faster than a practice of one can absorb, so the first hire belongs in the proposal's arithmetic before the signature.

What to settle before you sign

Settle payment mechanics, term and exit inside the document, because a direct agreement has no payer manual behind it to fill the silences. Name who submits what and where it goes. Name the days the plan has to pay and what happens when it does not. Name the term, the renewal and the notice either side gives to end it. Name what happens to care already scheduled when it ends.

The reading is the same reading a payer contract gets: the rate schedule, the term, the termination clause and its notice period, and the sentence covering claims in flight when the agreement stops. Practices that have bought software learn to read the exit before the demo, and the habit belongs here too, on a document you are helping to draft.

Two things move this from a template to a conversation with a health care attorney. One is a price structured as a fixed monthly amount per employee, since a periodic fee paid for care that has not happened yet is a different question from a fee per visit, and where you practice decides the answer. The other is any term tying payment to referrals or to volume sent by a third party.

The first agreement takes months and leaves you with a document you will reuse. The second conversation starts from a signed contract, a price you have defended once, and an administrator that has already paid you.