Between the ACA subsidy cliff, rising 2026 employer health costs, newly indexed ESRP penalties, a GLP-1–driven pharmacy spend squeeze, and a growing price-transparency crackdown, the ground is shifting fast for brokers. Below are five developments to watch, what changed, how each one hits your book.

ACA Subsidy Cliff: Extension Push Heats Up

House GOP bill introduced last week would extend the enhanced ACA premium tax credits for one year, while Senate Democrats are pressing insurers to warn members about potential premium spikes if subsidies lapse. The politics are fluid, but both chambers are now openly engaging the issue [Politico] [Axios]

Why it matters for brokers:

• Build two scenarios for Jan 1 renewals: with vs without the enhanced credits.
• Expect client questions on 2026 premiums and subsidy eligibility.
• Prep outreach lists for members most exposed to subsidy changes.

2026 Employer Health Costs: Another Big Jump

Health costs are set to climb again in 2026. Employer forecasts point to 6–7% growth even after plan changes and close to ~9% without them. The push comes from specialty pharmacy (GLP-1s included), higher utilization, and provider wage inflation. For brokers, that means earlier budget talks and a tighter playbook on plan design, funding, and vendor levers. [Reuters]

Why it matters for brokers:

• Socialize plan-design trade-offs early (networks, steerage, site-of-care).
• Pair cost control with behavioral health access and COE programs to avoid false savings.
• Use trend data to justify multi-year funding strategies (level-funded, captives, stop-loss optimizations).

Employer Mandate (ESRP) Penalties: 2026 Amounts Updated

As shared in the newsletter last month, the OBBBA is causing some big industry shake ups. The IRS indexing lifts the Affordable Care Act §4980H employer shared-responsibility penalties for 2026 to $3,340 (a-penalty) and $5,010 (b-penalty) per affected employee. [Thomson Reuters Tax]

Why it matters for brokers:

• Re-run pay-or-play models for ALEs; small affordability misses get more expensive.
• Tighten measurement & offers (95% rule, dependents) and validate affordability safe harbors.
• Align with payroll/HRIS on Form 1095-C data quality to avoid Letter 226-J surprises.

GLP-1 Whiplash + Pharmacy Trend: Cost Pressures Are Real

GLP-1s are now the top pressure point in pharmacy trend. Employers report pharmacy at roughly 24% of total spend, with Rx costs projected to rise 11–12% into 2026. At the same time, coverage is tightening—TRICARE For Life ended coverage for obesity-only GLP-1s as of Aug 31. This is a signal that more plans may add guardrails like prior auth, step therapy, or outcomes programs. Expect continued volatility in access, cost, and member expectations.[Business Group on Health ]

Why it matters for brokers:

• Prepare GLP-1 coverage grids (obesity vs diabetes indications, PA rules)
• Negotiate transparent PBM contracts (guaranteed net cost, audit rights, utilization levers)
• Educate members on clinical eligibility + alternatives (i.e weight-management programs, Centers of Excellence) to manage demand responsibly.

Price Transparency Crackdown: Fines & New Mandates Proposed

A bipartisan Senate bill—the Patients Deserve Price Tags Act—would codify hospital price transparency rules, raise non-compliance penalties, expand requirements to other sites of care, and push payers to offer real-time cost tools for members. [Health Leaders Media]

Why it matters for brokers:

• More usable price data supports steerage strategies (HPCNs, COEs, ambulatory migration)
• Real-time OOP tools improve member decision-making and your client reporting.
• Watch for plan & PBM disclosure duties that may add to employer fiduciary work.

The post 5 End of Summer Broker Alerts: Subsidies, GLP-1s, Penalties & More appeared first on Sana Benefits.

With a career rooted in making healthcare more personal and human-centered, Dr. Hunter is a perfect match for Sana’s mission: simplifying benefits, humanizing care.

About Dr. Grace Hunter

Dr. Hunter holds dual degrees in medicine and business from Stanford University, a Master of Science in Public Health from the London School of Hygiene and Tropical Medicine, and she completed her Internal Medicine residency at UCSF’s Primary Care Track. Her career spans both hands-on clinical care and large-scale system innovation—most recently serving as Chief Medical Officer and founding medical director at Miga, a virtual clinic focused on heart and metabolic health.

Dr. Hunter has led population health initiatives in California, spearheaded holistic care models under California’s CalAIM initiative, and continues to care for uninsured and low-income patients as a primary care physician at the Teton Free Clinic in Wyoming.

Why Sana? A Conversation with Dr. Grace Hunter

We sat down with Dr. Hunter to hear why she joined Sana and what excites her about Sana Care— our member-centric, physician-led virtual care service.

Q: What made you want to join Sana?

Dr. Hunter: I joined Sana because I believe we can take much better care of people when the payor and the provider are aligned, and when we proactively guide members through the healthcare system. Too often, patients are left to navigate a fragmented, opaque system alone. But at Sana, we’re linking benefits, virtual primary care, and care navigation in one seamless experience. That means we’re not just saying we care; rather, we’re showing it, across the full spectrum of someone’s health journey. It’s a rare and exciting opportunity to help reshape healthcare around people, not processes.

Q: How is Sana Care different from other virtual care models?

Dr. Hunter: In most healthcare settings, patients are lucky if they get 15 minutes with a doctor once a year, and follow-up is minimal. As a physician, that always felt deeply inadequate. At Sana Care, we’ve reimagined primary care to be continuous, responsive, and team-based.

We offer both synchronous visits (live phone and video appointments) and asynchronous messaging, so patients can reach out on their own schedule and hear back from us, often within the hour. That kind of timely connection makes a huge difference in building trust and managing ongoing care.

Because we’re physician-led, we’ve custom built our tools and workflows around how clinicians actually want to deliver care. We’re not rushed. We can check back in, manage chronic conditions, review labs, and guide patients to trusted in-person partners, all while staying deeply connected to their journey.

We also have a fantastic multidisciplinary team, including care navigators who help patients access high-quality, in-network specialists, schedule appointments, and make sure nothing falls through the cracks. Our patients see us as their home base, and we see every question, message, and referral as a chance to show that we care, not just about outcomes, but about people.

Q: What does offering Sana Care mean for Sana members?

Dr. Hunter: It means our members have real support—not just when they’re sick, but anytime they need guidance, have a question, or want to feel heard. There’s no cost to use Sana Care and no limit to how often you can reach out. You get a dedicated care team that sees you as a person, not just a patient.

We’ve had members send thousands of messages over a few years—sometimes just to double-check something small, like, “Hey, I noticed this rash—should I be worried?” or “You mentioned white rice might spike my glucose. What about brown rice?” It’s truly like having a doctor in the family you can just text when you think of something without feeling like it has to be “big enough” to warrant a full appointment.

At the same time, we’ve also been by our patients’ sides through major life events like helping navigate cancer diagnostics, coordinating treatment plans, or working with specialists to diagnose something as serious as a brain tumor and get them into expert hands quickly for emergency neurosurgery. We’re here for all of it, both the little questions and the life-changing ones.

A Patient Story from Dr. Hunter

When Marcus, a 42-year-old father of two, woke up with a lingering cough and fatigue, he didn’t want to sit in a waiting room or spend half his day navigating urgent care. So he messaged Sana Care before his first meeting of the day.

Within 30 minutes, a Sana Care physician had responded. By lunchtime, Marcus felt reassured about his symptoms and picked up a prescription.

But the story didn’t end there.

After a few days, Marcus had more questions so he sent another message to his provider. He mentioned rising blood pressure and feeling unusually stressed. His provider suggested a full wellness check. Over the next few weeks, Marcus:

• Started blood pressure treatment with remote monitoring
• Began therapy with a trusted, in-network mental health provider
• Got help from his Sana Care medical assistant and care navigator to schedule recommended cancer screenings and coordinate lab work

Three months later, his blood pressure is under control, he’s sleeping better, and for the first time in years, he feels caught up on his health.

“I messaged about a cough—and ended up with a team that really sees the whole me.”

At Sana Care, we meet you where you are and then stay with you every step of the way. Whether it’s an acute concern, a chronic condition, or preventive care, our integrated team is here to make healthcare feel human again.

What This Means for Sana’s Future

Dr. Hunter’s leadership marks an exciting new chapter for Sana. As we continue to expand Sana Care into more states and enhance our virtual and in-person care offerings, her experience will be invaluable in helping us design care that puts people first.

“We’ve accepted broken healthcare for too long. Sana is rewriting that story—one relationship, one member, and one moment of care at a time.” — Dr. Grace Hunter

About Sana Care

Sana Care is a virtual primary care service available to adult members on a Sana health plan, at no extra cost to them. Sana Care includes:

• Unlimited virtual communication and visits with licensed providers
• Prescription management
• Chronic care support
• Guidance on specialist care and in-person visits
• Help from expert care navigators to coordinate next steps
  

Want to learn more? Learn more here.

Welcome, Dr. Hunter!

We’re proud to welcome Dr. Grace Hunter to the Sana team. Her leadership will help us continue to deliver healthcare that’s simpler, more supportive, and more human.

The post Meet Dr. Grace Hunter, Sana’s New Chief Medical Officer appeared first on Sana Benefits.

A key component, Title II: The American Healthcare Choices Act of 2025, embeds deregulation and tax changes directly affecting benefits markets—elevating broker roles from compliance facilitators to strategic advisors in a competitive landscape. [Congress]

This blog breaks down what’s changing, compares the “before” vs. “after,” and highlights what it means for your clients and commissions.

The ACA and CAA era was about compliance. This next chapter? It’s all about open competition. And as a broker, your role is about to evolve—fast.

Medicaid Changes

The bill’s Medicaid overhaul introduces stricter eligibility rules, including work and income verification requirements. While this shrinks public coverage rolls, it also creates a surge of newly uninsured individuals—many of whom will turn to brokers for help finding new plans.

Before:
Brokers rarely engaged with Medicaid enrollees, as most were covered automatically or through government outreach.

After:
New rules require verification of income and work status, pushing ~7.8 million people off Medicaid by 2034 [KFF]. Many will seek individual ACA coverage, employer-sponsored plans, or short-term options—markets where brokers are essential.

This is a massive opportunity for brokers:

• Displaced enrollees will need help evaluating ACA, ICHRA, short-term, or employer-sponsored options.
  
• State-to-state variations mean local expertise will matter more than ever.
  
• Brokers who proactively build Medicaid offboarding funnels and outreach campaigns can grow their book significantly—especially in rural and low-income markets.

Why Brokers should care:

Medicaid may not have been your market before. But starting now, it absolutely is.

ACA Marketplace Shifts

The ACA isn’t going away, but it’s changing fast. From disappearing subsidies to shortened enrollment windows and heightened fraud enforcement, brokers who rely on marketplace sales must prepare for leaner margins, faster deadlines, and higher compliance standards.

Before:
ACA plans offered enhanced subsidies, broad access, and a long open enrollment season through January 15.

After:

• Subsidies disappear end of 2025, with premiums expected to rise 15–20% [Vox]
  
• Open enrollment ends December 15, cutting the window by 30 days [Enroll Insurance]
  
• Brokers face audits: CMS already suspended 850+ agents for improper enrollments [Washington Post]
  

Why brokers should care:
Expect a surge in client questions, tighter eligibility rules, and an uptick in compliance headaches.

Employer-Sponsored Plans & Telehealth

Employers offering high-deductible plans just got a win: telehealth pre-deductible coverage is now permanently allowed. This change makes HDHPs more flexible—and gives brokers new value to spotlight when designing or pitching group plans.

Before:
The IRS telehealth “safe harbor” for HDHPs had expired in 2024, limiting coverage flexibility.

After:
The bill makes the safe harbor permanent and retroactive to January 1, 2025 [Senior Market Sales].

Why brokers should care:

This opens the door for employers to offer first-dollar telehealth without jeopardizing HSA eligibility—an attractive benefit for cost-conscious groups.

Rural Hospital & Provider Landscape

Rural healthcare access has long been fragile. With new funding allocated to rural hospitals—but deep Medicaid cuts still on the table—the stability of networks in less populated areas remains uncertain. Brokers in these regions should stay alert to shifting coverage landscapes.

Before:
Rural providers were under threat from ongoing Medicaid underfunding and provider consolidation.

After:
A $50 billion Rural Hospital Fund aims to stabilize care access [Health Action Council]. But Medicaid cuts may still undermine rural coverage in the long term.

Why brokers should care:
Brokers in rural markets must stay in tune with network shifts, hospital partnerships, and potential plan exits.

Administrative & Compliance Burden

This bill doesn’t just reshape coverage—it increases scrutiny. With new verification rules and aggressive oversight, brokers now face a heightened risk of audits and suspensions. Operational discipline and documentation have never been more important.

Before:
Brokers dealt with income checks mainly on the ACA side. Medicaid enrollment was largely passive or state-managed.

After:
Both Medicaid and ACA now carry stricter verification requirements and heavy broker oversight. CMS is actively auditing agents and suspending licenses for noncompliance [Washington Post].

Why brokers should care:
Broker operations must modernize. Compliance systems, documentation protocols, and staff training are no longer optional.

Key Broker Takeaways:

These policy shifts aren’t abstract—they directly affect a broker’s book of business. Whether you sell individual ACA plans, worksite benefits, or group coverage, the One Big Beautiful Bill brings both risk and opportunity. This section breaks down the big takeaways—and what smart brokers should do next.

• ~7.8M clients leaving Medicaid will need new plans
  
• ACA premiums rise sharply post-2025
  
• Enrollment window tightens (Dec 15 deadline)
  
• CMS audits rising — documentation matters
  
• Telehealth safe harbor boosts HDHP flexibility
  
• Rural funding helps, but Medicaid gaps may widen

The post Broker Pivot: The “One Big Beautiful Bill” Era is here. appeared first on Sana Benefits.

Many telehealth services come with frustrating limitations: no continuity of care, unclear next steps, and one-off visits with random providers who don’t know your health history. That’s where Sana Care changes the game.

What is Telehealth, and Why Do People Use It?

At its core, telehealth is any form of healthcare delivered remotely—whether through video calls, messaging, or remote monitoring. It skyrocketed during the pandemic, and today, it’s a go-to option for routine check-ups, behavioral health support, and even prescriptions.

For patients, the appeal is clear:

Convenience – No more long drives, waiting rooms, or scheduling hassles.
Affordability – It often costs less than in-person visits.
Better Access – It’s a lifeline for those in rural areas or with mobility challenges.
Mental Health Support – Virtual therapy is discreet and easy to access, removing common barriers to care.

Employers love telehealth, too, because it’s a cost-effective way to offer employees better healthcare access. More engaged employees = a healthier, happier workforce.

The Downside of Traditional Telehealth

Despite its perks, traditional telehealth has some major flaws:

Lack of continuity – Patients often see different doctors every time, making follow-ups tricky.
Limited guidance – Many telehealth services stop at a virtual visit without helping patients navigate their next steps.
Some conditions require in-person care – Many patients end up needing an office visit anyway, which can feel like a waste of time.

In fact, while 89% of patients would recommend their provider after a telemedicine visit, only 76% would recommend a video visit alone. Why? Because most virtual care feels disconnected and transactional.

How Sana Care is Doing Things Differently

Sana Care isn’t just another telehealth service—it’s a fully integrated virtual primary care and care navigation experience included with all Sana health plans at no extra cost to members. Here’s what makes it different:

Dedicated Care Teams – Instead of bouncing between random providers, members work with a care team that actually knows their health history.

Expert Care Navigation – If in-person care is needed, Sana Care helps patients find in-network specialists and guides them through the next steps.

$0 Cost to Members – No surprise fees. No copays. Just high-quality virtual care.

Convenience – Members can reach out anytime, and a care team member will respond during business hours. Having a direct line to medical support provides peace of mind.

Sana Care: A Better Virtual Care Solution

For brokers, offering Sana means providing a premium virtual care experience that businesses and their employees love. It’s healthcare that actually works—seamless, connected, and built to guide patients to the best possible care.

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We have many resources to help make Sana available to your clients seamlessly. If you would like to learn more on behalf of a specific client partner, start by requesting a group quote.

The post Why traditional telehealth falls short–and how Sana Care does it better appeared first on Sana Benefits.

That’s where we come in. With a 93% customer satisfaction rating, our health plans are designed specifically for small businesses—offering cost savings, flexibility, and standout benefits like $0 virtual care and care navigation through Sana Care.

To help you communicate the value of better health insurance to your clients, here’s a quick breakdown of why modern, more affordable health plans are changing the game for small businesses.

1. Real Cost Savings for Small Businesses

Tax Advantages

Many small businesses don’t realize that self-funded health plans like Sana’s can offer significant tax advantages over traditional fully insured plans. Our level-funded plans are taxed less, helping businesses save.

Lower Pharmacy Costs with SmithRx

Sana partners with SmithRx, a transparent Pharmacy Benefits Manager (PBM) that ensures members have access to lower-cost medications. This means predictable prescription pricing and substantial savings for employers.

Fair and Flexible Reimbursement

Unlike traditional insurance carriers, Sana’s reimbursement model blends direct contracts, networks, and single-case agreements to offer members more flexibility while keeping costs in check.

2. Sana Care: A Game-Changer in Virtual Healthcare

One of the biggest reasons small businesses love Sana is Sana Care—our high-quality, no-cost virtual healthcare solution that provides comprehensive care without barriers.

$0 Cost for Members

Unlike some traditional virtual care options, Sana Care is 100% included in Sana plans, members making high-quality care more accessible and affordable for employees.

Beyond Just Virtual Care

Sana Care isn’t just for minor issues. Our dedicated care team can diagnose, treat, and manage ongoing conditions—providing the same level of care as an in-person primary care doctor.

Guidance to Best In-Person Care

If a member needs an in-person visit, our care navigators will guide them to the best available provider—ensuring they receive the right care at the right time.

With Sana Care, businesses get a built-in virtual care solution that reduces costs, increases healthcare access, and improves employee well-being—all at no extra charge.

3. More Freedom and Flexibility

Flexible Network

Unlike restrictive networks, Sana can work with any provider who will work with us—giving employees the freedom to see the doctors they trust.

Customizable Plans for Employees

Employees can choose a plan that fits their needs with different deductible and out-of-pocket maximum options, providing a sense of control and satisfaction in their healthcare choices.

4. Level-funding = Cost Savings and Predictability

For those unfamiliar with level-funded health insurance plans, here’s a helpful definition.

“A level-funded health plan is a type of self-funded health plan where the employer pays a fixed monthly fee to a third-party health services company to cover all of the administrative costs and what they anticipate to be their monthly employee claim costs.”

With Sana’s level-funded plans, small businesses get:

This balance of transparency, cost control, and savings makes Sana an easy sell to small businesses.

4. Plans Designed for Small Businesses

Small businesses have different healthcare needs. That’s why Sana offers multiple plan options—ensuring there’s a perfect fit for every employer.

Unlike traditional carriers, we keep things simple and affordable so businesses can focus on what they do best.

5. Why This Matter for Brokers

As a broker, you want to help small businesses find the best health plans. With Sana, you’re offering:

Cost savings through lower taxes, fair reimbursements, and pharmacy savings.
More choices for employers and employees.
Sana Care and virtual healthcare solutions to improve access to care.
Level-funded plans that provide stability and refunds when claims are low.
Simplified plan options designed specifically for small businesses.

At the end of the day, Sana makes healthcare easy, affordable, and accessible. And that’s exactly what small businesses need.

Final Thoughts

If you’re looking for a health insurance partner that actually works for small businesses, Sana is the answer. By introducing your clients to Sana’s affordable plans, premium virtual care through Sana Care, and transparent pricing, you’re offering real value that keeps employees happy and businesses thriving.

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We have many resources to help making Sana available to your clients seamless. If you would like to learn more on behalf of a specific client partner, start by requesting a group quote.

The post A smarter approach to small business health insurance appeared first on Sana Benefits.

But here’s the good news: Sana does things differently. We’ve put together a list of key facts about our plans to help you understand why Sana is the perfect choice for small businesses. Let’s dive in!

1. Employees can be located anywhere in the U.S.

With Sana, there are no state restrictions for employees using our health plans. For businesses with remote team members, this is a huge win.

The only location rule? Your client’s business needs to be based (or “domiciled”) in one of these states: Alabama, Arizona, Illinois, Indiana, Kentucky, Michigan, Ohio, Oklahoma, Texas, Virginia, or Wisconsin. And the list is growing!

Right now, we’re proud to serve 2,000 businesses, 20,000 employees, and 30,000 members. Your clients can join them!

2. Employee requirements are minimal

All small businesses need to be eligible for a Sana plan are two employees and five total individuals. Of those five, not all need to be employees. Some can be spouses and children.

Including families is seen as a major benefit to many team members, so make sure to champion that point to clients.

3. Under 100

While we could certainly handle larger businesses, Sana works best for small businesses with between 10 and 99 employees. It’s set up to meet their needs and has become a sweet spot we genuinely enjoy servicing.

“We’ve been with Sana Benefits for going on 3 years now. They are the only reason I was able to offer benefits to my team with ease. The platform, the team, the explanation of services and benefits makes giving healthcare as a business owner a breeze.” – Erica Davis

4. 24-48 hours

Brokers can get a group quote quickly with Sana. The process is simple, just submit the following required elements:

• Census – Employees & Dependents
• First & Last Name
• Date of Birth
• Gender
• Zip code
• Relationship (EE, SP, CH)
• Current and Renewal Rates

Then volunteer any plan documents, SPDs, SBCs, invoices, and experience you can provide (these aren’t required, but are helpful).

After that you can typically expect a turnaround time of 48 hours, but sometimes we even get quotes back that same day.

Major benefit: With Sana, no medical questionnaires are required for quoting! We don’t believe in extra steps or invasive procedures like that.

5. More than a network

Sana Care

Adult Sana members get access to Sana Care for free. What’s Sana Care? It’s our virtual primary care and care navigation service that allows members to simply message the Care Team to get personalized and convenient care that’s 100% included in their plan. Unlike other services, such as telehealth, with Sana Care, they get a dedicated care team, that is with them for every step of their care journey.

Sana Care can virtually diagnose and treat patients, facilitate personalized care coordination and/or referrals to trusted in-network specialists, and can even get prescriptions written or refilled. 

See if Sana Care is available in your state.

Service

Our clients love the level of service they receive from Sana. It’s important to us that our customer support options mitigate any issues because we want them to be happy (and they are!)

“In an age of over priced insurance, Sana was a huge surprise! The pricing is amazing and the coverage is even better! Highly recommend Sana for any small business!” – Philip Nelson

6. Preferred doctors

Sana will often set up single case agreements or direct billing arrangements with many providers that aren’t currently in our network to better serve the needs of patients. At the same time, we’re constantly expanding access to more doctors and facilities for members. Together, these two strategies mean patients can see their preferred doctor, as opposed to whatever doctor will see them.

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Our team is always here to help support you in your journey to champion Sana. If you need a group quote, just ask!

The post 6 health insurance facts that help brokers sell Sana appeared first on Sana Benefits.

This is one of the hardest things we’ve ever had to do at Sana. We have had to say a lot of goodbyes, and I mostly feel awful at this moment. The impacted employees are talented, mission-driven people, many of whom are not only colleagues but also friends.

• To anybody reading this who is hiring: You would be lucky to hire these folks. They are excellent. Please reach out to our people team; we are happy to make introductions and serve as references.

• To our customers & partners: Nothing is changing about our health plans or the service we are delivering. We kept the majority of our operations team in place to ensure no interruptions or issues with our service and I expect our product to keep getting better over time.

So, what’s going on?

Since Sana’s founding in 2017, we have been venture-funded. That meant we spent a lot of money on growth and a lot of money on R&D. It was ok we weren’t profitable because we could keep raising venture dollars to fund the business. We prioritized investing in the future over profitability today. I’m grateful for that time, because it allowed us to build the special company and product we have today.

The world has changed, however, and venture funding is harder to come by now. Particularly for companies in the healthcare and insurance worlds (we check both boxes). The hard fact is this new environment rewards profitability today over future investments. We have to reposition ourselves accordingly.

Fortunately, we are in a position where we have the choice to be profitable. The cuts we make today mean we are generating positive cash flow. Immediately. We will continue to invest in growth and R&D, but only to the extent our profits support that investment. 

I spent a lot of time in the last few weeks thinking about what this transition means for our company. Here are a few thoughts:

Back to basics

I am inspired by the leadership Ryan Peterson is showing in his return to the CEO role at Flexport. The strategy is so simple: listen to your customers, and then build the things they need. I realize over the last two years I have been too mired in spreadsheets, too focused on the abstract idea of “scaling”, and what I need to do is rediscover what makes Sana great. I am going to spend my next year listening to customers and doing things that don’t scale. It’s what I should have been doing all along.

Going “all in” on Sana Care

Earlier this year we launched Sana Care, and the success that product has had out of the gates is extraordinary. Putting a virtual concierge doctor in people’s pockets, bundled with a health plan, seemed like a compelling idea a year ago — but the engagement and satisfaction levels surpassed anything I hoped for. NPS has consistently been north of +90 while reducing net claims spend. It feels like the future of healthcare. We are doubling our investment in Sana Care R&D as of this week in spite of our general expense cuts. The future there is as bright as ever.

Sustainable growth

Our ambition remains to build a generational business that transforms healthcare. Which means we need to grow quickly, efficiently, and thoughtfully. Our integrated payvidor model is very different from what you can find elsewhere in the small group market and we have been fortunate to partner with a fast-growing cohort of brokers who are looking for a better way forward for their clients. We are going to continue to invest in building these relationships and will be rolling out initiatives in the coming months to demonstrate that commitment. If you are a broker interested in selling innovative & affordable small group health plans, get in touch. 

The most intense and difficult periods in life are often, in hindsight, the most meaningful. Six years ago Nathan and I started Sana, and those years have not been easy. Today was not easy. I don’t expect the coming years to be easy either. But through all that struggle we are building something of which I’m immeasurably proud. Something that makes a real difference in healthcare.

I am sad today, and admittedly this year has been humbling for me as an entrepreneur.

At the same time, I am incredibly excited about where we are going. The future’s still bright.

-Will

The post November 2023: Sana’s Company Update appeared first on Sana Benefits.

PEOs can change the game for SMBs looking to reduce overhead, streamline operations, and access affordable small group health insurance. 

A PEO is a third-party organization that partners with businesses to manage specific administrative tasks primarily related to human resources. Understanding the PEO’s role and benefits allows you to make informed decisions about optimizing your resources and managing your HR responsibilities.

PEOs can provide SMBs with a comprehensive solution to various administrative challenges. To fully leverage their capabilities, it is crucial to recognize their role in the following key areas of your business operations:

Payroll

Managing payroll is one of the primary features of a PEO. This includes:

• Paying employees on time
• Handling tax withholdings
• Completing end-of-year tax forms

Benefits administration

PEOs help businesses design and manage employee benefits packages, which can include:

• Health insurance
• Retirement plans
• Wellness programs
• Employee assistance programs
• Service discounts
• Enrollments, changes, and terminations

Workers’ compensation

PEOs can process workers’ compensation claims for you. They can also help you get better rates for workers’ compensation insurance because they have collective bargaining power and industry knowledge.

Regulatory compliance

PEOs help you navigate employment laws and regulations. They use their expertise to help you stay compliant and avoid potential legal complications. This includes helping you adhere to labor laws and ensuring that employment practices are fair and nondiscriminatory.

Human resources management (HRM)

PEOs often also provide comprehensive HRM services, which include tasks such as:

• Creating and updating employee handbooks
• Managing onboarding and offboarding processes
• Handling employee complaints
• Helping with performance management

Risk management

Many PEOs have risk management experts who can help you identify potential risks and develop strategies to combat them. For example, they can help you create safety protocols or provide training sessions. They can also check for compliance with Occupational Safety and Health Administration (OSHA) regulations.

Employee training and development

PEOs may also offer training and development programs to help you invest in your employees. They give you access to training resources that you may not have access to otherwise, including:

• Technical training
• Soft skills development
• Compliance and regulatory training
• Cross-cultural training and language learning programs
• Personal development and wellness sessions

Recruitment and hiring

Some PEOs also help with recruitment efforts by:

• Posting job listings
• Screening applicants
• Conducting interviews
• Managing the end-to-end hiring process

Legal consultations and support

Last but not least, PEOs often provide legal expertise and consultation on employment-related issues, including:

• Handling disputes
• Understanding updated labor laws
• Drafting compliant employment contracts

This legal support can be invaluable for small businesses, as they often don’t have access to the same legal resources that larger corporations do.

Healthcare costs are rising and as a result, businesses are always seeking more efficient and cost-effective ways to provide quality health benefits to their employees. 

PEOs offer a streamlined approach to health insurance management. But like any solution, group health insurance through PEOs has pros and cons.

Pros

PEOs offer numerous advantages that can help your business access affordable health insurance and relieve administrative burdens.

Economies of scale

The term “economies of scale” refers to lowering the cost of a service or good by consolidating effort or volume. In health insurance, this means that the greater the number of businesses that pool together, the lower their healthcare costs will be. 

PEOs pool together employees from various small businesses, which increases their purchasing power when negotiating health insurance rates. The cost of benefits gets spread out across more employees, and can lower your cost per employee.

This means you can access more competitive premium rates and a wider variety of coverage options than you might secure on your own. You can offer your employees high-quality healthcare plans without breaking the bank.

Administrative relief

Managing health insurance can be time-consuming and labor-intensive, especially if your HR resources are limited. PEOs do all the heavy lifting of benefits administration, freeing up precious time for you to focus on other important areas of your business. They reduce your administrative burdens, minimizing the risk of health insurance management errors.

Compliance support

Staying compliant with ever-changing healthcare regulations can be a challenge for many small businesses. PEOs provide experts in the latest healthcare regulations and laws. They make sure the healthcare plans you offer align with current legal requirements. They also help you navigate the complexities of the Affordable Care Act (ACA) and other health insurance mandates — an invaluable resource.

Access to a wider range of benefits

While many PEOs offer basic health insurance, they also have relationships with providers that allow them to provide many additional benefits, such as:

• Dental benefits
• Vision plans
• Wellness programs

Partnering with a PEO allows you to offer robust, competitive benefits packages like those of larger corporations. Such diverse benefits packages can help you attract and retain top talent in a competitive market and increase job satisfaction.

Cons

While PEOs offer notable advantages, they also come with their own set of disadvantages.

Potential loss of control and flexibility

Since you hand over the reins of benefits administration when partnering with a PEO, you often have to give up some decision-making power regarding your benefits offerings. The PEO may predetermine specific health insurance plans, coverage options, and even providers. You may have limited flexibility to tailor your offerings to the unique needs of your business or workforce.

Cost of services

While PEOs can offer economies of scale, you do have to pay for their services. PEO fees can sometimes be substantial, especially if you’re a very small business. These fees can add up over time, and the cost savings from group rates might not always make up for the expense. In some cases, you may end up paying more overall to provide health benefits.

Group rate fluctuations

Because PEOs are rated based on a “pool” versus individually, your pooled group rates could go up even if your group’s claims are low. So depending on your group, pooling could hurt or help come time for renewal. Additionally, most PEO plans renew on 1/1 so depending on when your group joins the PEO, your first renewal could come quickly and be more pricey than you had anticipated.

Lack of personalization

Since PEOs serve multiple businesses and pool them together, your unique culture, values, and needs may get lost in the shuffle. PEOs are more efficient, but you may have to sacrifice personalized attention and customization in exchange. This can lead to a one-size-fits-all approach to benefits that may not meet the needs of every employee. 

Long-term commitment

Finally, many PEOs require businesses to enter into extended contracts. If you decide that the PEO isn’t the best fit for your business or find a better alternative, you may have to jump through hoops or pay a costly sum to break the contract.

Besides looking at the pros and cons of a PEO, you also need to make sure it’s the right fit for your business. Ask yourself a few questions to determine if a PEO is the answer to your administrative challenges and employee needs.

How much time is my business spending on HR tasks?

If you find that you’re spending many hours on administrative duties like benefits administration, payroll, or compliance, you may need external assistance from a PEO. If your business operates efficiently with your current HR processes and manages administrative tasks easily, a PEO may not be necessary.

Do we have the expertise and capability to offer competitive benefits packages?

A business that struggles with negotiating favorable terms with payers or lacks the knowledge and expertise to curate attractive benefits might benefit from a PEO’s bargaining power and expertise.

If you have strong relationships with insurance providers, can negotiate favorable terms on your own, and have internal experts who can create and offer competitive benefits packages, a PEO might not add enough value to justify the cost.

Are we equipped to handle compliance and regulatory changes?

A PEO can be a valuable asset if your business struggles to keep up with the ever-changing employment regulations or doesn’t have a dedicated legal team. Conversely, if you have someone who keeps up with the latest regulatory changes and keeps you compliant, you don’t really need external assistance.

Is our business growing rapidly?

If you anticipate or are experiencing rapid expansion, evaluate whether your current internal HR processes can keep up. If not, a PEO might be the solution that keeps growth from compromising operational efficiency.

You might not need a PEO if you have no issues with employee onboarding, process transitions, and HR tasks amid rapid expansion.

How well are we managing employee-related issues and concerns?

Frequent employee concerns and disputes or a high turnover rate may indicate gaps in your HR management. A PEO can fill in those gaps. If you have a strong internal HR team that fosters a positive work environment and addresses concerns promptly, you may not need a PEO’s intervention.

As a small business, you have access to a diverse variety of plan types, some of which work well with PEOs. Understanding how they interact with one another can help you decide if PEOs are right for your business and employees.

Fully insured plans

Traditional fully insured plans are the most common type of health insurance in which you pay a premium to the insurance carrier. PEOs typically have pre negotiated rates with insurance carriers for these plans. 

They also manage the relationship between you and the payer and handle all administrative tasks. This means you can access better premium rates and reduce administrative burden.

Self-funded plans

In self-funded plans — also known as self-insured plans — you take on the financial risk of providing health insurance to your employees and pay for medical claims out of pocket. A PEO provides invaluable support by providing third-party administrative services and offering risk management insights so you can set aside appropriate funds for anticipated claims.

Level-funded plans: How Sana works with PEOs

Sana is a level-funded plan that combines the cost savings of a self-funded plan with the financial stability of fully insured plans. You pay a set monthly premium to Sana, part of which goes into a claims fund. If your claims exceed the amount in the fund, stop-loss insurance covers the excess. And if your monthly premium is higher than the total of claims you paid, you get refunded based on a few factors including your total annual spend.

It’s easy to use Sana as your health benefits provider and keep your PEO to manage your payroll and administrative tasks. Sana can accept an automated file feed directly from your PEO or your plan administrator can manually update enrollments in the Sana portal. You can also enroll in Sana through the Sana portal and upload your benefits enrollment information into your PEO to align with your payroll. 

If you choose to leave your PEO, Sana can keep you covered with a full suite of benefits.

Related: Self-Funded vs. Level-Funded plans: What’s the Difference?

Health maintenance organizations (HMOs) and preferred provider organizations (PPOs)

In an HMO, members select a primary care physician (PCP) to receive services from, and the PCP provides referrals for specialists. PPOs are like a more flexible form of HMOs. They allow members to see any doctor or specialist they want without a referral, even if they’re out of network. But staying in-network typically keeps their out-of-pocket costs lower. 

When PPOs and HMOs partner with a PEO, they get access to the PEO’s established network of PCPs and specialists. The PEO also handles the administrative side and provides educational resources to employees.

The post Health insurance 101: Professional employer organization (PEO) appeared first on Sana Benefits.

This blog post focuses on one plan option: exclusive provider organization (EPO) plans. We’ll cover what they are, how they work, and their benefits and limitations to help you decide whether EPOs suit your small business and its employees.

An exclusive provider organization (EPO) insurance plan is a type of health insurance that offers its members a network of specified healthcare providers to choose from. They are a common option among businesses, and nearly a third of plans selected in the Affordable Care Act (ACA) Marketplace are EPO plans. 

You can think of EPO plans as a mix of two other types of health plans: a health maintenance organization (HMO) and a preferred provider organization (PPO). It tries to find a middle ground between them by managing costs while still giving you a degree of flexibility in where you get healthcare.

While there are similarities, several features distinguish EPO plans from other health insurance options. Before we dive into details, here’s a quick overview of the four most common types of health insurance plans and how they compare:

Let’s look closer at EPO plans and see how they compare to the other three:

Both EPO and health maintenance organization (HMO) plans limit coverage to in-network providers. However, an HMO requires a referral from a primary care physician (PCP) to see a specialist, while an EPO does not. Additionally, EPO premiums are higher than those of an HMO because of the added flexibility EPO plans offer.

An exclusive provider organization (EPO) is a type of health insurance plan where the coverage only pays for care provided within its network, except for life-threatening emergencies. If you use services outside the EPO’s approved network, you’ll have to pay the total cost of care. EPO plans typically do not require members to choose a primary care physician (PCP) or obtain referrals to see specialists, offering flexibility in direct access to specialty care. They tend to have comparatively lower premiums but restrict coverage to in-network providers.

Point-of-service (POS) plans are more flexible than EPOs regarding coverage and offer both in- and out-of-network coverage, albeit out-of-network services are usually covered at a higher cost. Unlike EPO plans, POS structures still require a designated primary care physician who can provide referrals to specialists. EPO plans typically have lower premiums than POS plans.

Preferred provider organization (PPO) plans are the most flexible and comprehensive options. While both PPO and EPO plans provide flexibility in accessing specialists, the key difference lies in the out-of-network coverage: PPO plans offer it, while EPO plans don’t. Also, EPO plans have lower premiums compared to PPO options due to their network restrictions. 

Find the most updated information about plans and prices through the government portal at healthcare.gov. 

There are benefits and drawbacks to offering EPO insurance plans. If you are serious about attracting top talent via enticing benefits packages, considering the pros and cons of EPO insurance options is critical in determining whether these plans are suitable.

Benefits of using an EPO

• Cost-effective: EPO plans are one of the most affordable options when providing health insurance. For small businesses with limited resources and insurance budgets, the affordability of EPO plans makes them an attractive choice. 
• No referrals required: With an EPO plan, members do not need to endure long wait times or jump through hoops to get a referral from their doctor. EPO plans allow you to contact and make an appointment with any specialist within your exclusive provider network.
• Large network: Similar to HMOs, EPO plans usually provide access to an extensive network of providers, giving members ample choices regarding physicians and specialists. 
• No need to choose a PCP: Since referrals from PCPs aren’t required, those with EPO insurance plans don’t have to choose a primary doctor to be eligible to enroll. 

Limitations of an EPO plan

• Network restrictions: Even though EPO plans grant access to a relatively large network of providers, the inability to go out-of-network is still a major drawback of these types of plans. Out-of-network services are sometimes necessary, and all medical expenses incurred outside the exclusive provider network would be out-of-pocket costs to those with an EPO plan. Medical expenses can quickly amount to tens of thousands of dollars without insurance coverage, exposing one of EPO plans’ most significant disadvantages. 
• Regional limitations: EPO plans are generally regional in nature, meaning their network and providers serve a specific geographic area. While this regional focus can be advantageous for those living within the plan’s designated region, it poses challenges for individuals with dependents residing outside of this area.
• Burden of responsibility: The details of which provider or medical procedure is covered under an EPO plan aren’t always apparent to those signing up. This means those choosing EPO plans have more responsibility to ensure they aren’t accidentally receiving services out-of-network or without pre-authorization. For example, if a member receives a medical service without realizing it requires pre-authorization, they would be liable for the entire cost of the procedure. 

You should do a thorough audit of your business’s needs and goals before deciding if an EPO plan is suitable. Remember, your employees’ needs are a key part of the conversation, so having an open, two-way dialogue with them is crucial for accurately evaluating whether an insurance plan is right for your business.

Here are some questions to ask to help determine whether an EPO is the best fit for your small business:

• How will employees react to being restricted to in-network providers?
• Do your employees have special, specific, or rare medical needs?
• Does the EPO network include a diverse range of specialists and facilities?
• Will employees find it convenient that they don’t need to choose a primary care provider? 
• How easy is it to get pre-authorization for certain procedures in the EPO plan?
• Does the EPO plan cover preventative care and wellness programs?
• How have other similar small businesses fared with EPO plans?
• What’s the reputation of the insurance provider offering the EPO plan?
• How do the costs of premiums, out-of-pocket-maximums, deductibles, copay, and coinsurance compare to other plans?

Comparing EPO plans with other health insurance options

Remember, the choice to offer health insurance is an investment, not just in the well-being of employees but also in your company’s long-term success. That’s why researching and comparing EPO plans with other options is essential. 

EPO plans are viable offerings within level- and self-funded structures, and small businesses should do their research to understand the differences. When looking at options, it’s critical to exercise due diligence and compare EPOs with other plans to find the one that best suits your business and employees’ needs.

Sana Benefits

Sana’s mission is to help small business owners offer their employees affordable, high-quality health insurance. With Sana, employees receive comprehensive health coverage at a fraction of traditional costs, flipping the script on the myth that small businesses can’t afford health insurance.

Our PPO plans and flexible network make health insurance radically more accessible and affordable than ever while maintaining a high standard and quality of care. To find out if Sana Benefits is right for your small business, contact us and get a quote today.

The post Health insurance 101: Exclusive provider organization (EPO) plans appeared first on Sana Benefits.

Group health insurance renewal basics

Understanding the fundamental aspects of a health insurance renewal is the first step towards a smoother, more efficient renewal process.

What does a health insurance renewal mean?

A health insurance renewal is the process of extending your current health insurance policy for another plan year. This typically involves:

• Reviewing your existing policy
• Assessing your current and future healthcare needs
• Deciding whether to continue with the same plan, switch to a different plan, or make changes to your current plan

When does the health insurance renewal process usually occur?

The health insurance renewal process usually occurs annually, typically at the end of the policy year. However, the exact timing can vary depending on the insurance company and policy terms.

Why do renewals happen on an annual basis?

Renewals happen on an annual basis to allow for adjustments based on changes in healthcare needs, insurance regulations, and market conditions. An annual review ensures that the health insurance plan continues to meet the needs of the employer and provides adequate coverage for employees.

Group health insurance renewal process

The group health insurance renewal process involves several steps. Each step is crucial in ensuring you end up with a health insurance plan that best suits your business and your employees. This process is cyclic and repeats every time your insurance policy is up for renewal.

1. Underwriting review

The insurance company does a thorough examination of the current policy, external factors, and risk scoring to determine any changes in cost to your current plan.

2. Renewal notice

The insurance company sends a renewal notice detailing the terms of the new policy, including any changes to coverage, benefits, and cost.

3. Internal review

The business assesses the healthcare needs of its employees to determine if the current plan still provides adequate coverage.

4. Market analysis

The business researches the health insurance market to understand current trends, offerings, and pricing.

5. Decision

The business makes a decision based on internal review and market analysis.

6. Communication and enrollment

The business communicates the changes to its employees and conducts the enrollment process.

7. Implementation and management

The business implements the renewed policy and manages it throughout the plan year.

Factors that affect group health insurance renewals

Several factors can influence the outcome of group health insurance renewals, leading to price changes. Understanding these factors can help you anticipate potential challenges and strategize effectively.

Premiums

Health insurance premiums are the amount you pay to the insurance company for your policy. They can increase at renewal due to factors such as:

• Higher healthcare costs
• Increased usage of benefits
• Changes in the risk profile of your group

Claims

The number and cost of claims made under your policy can significantly impact your renewal. A high number of expensive claims can lead to an increase in premiums as the insurer seeks to cover these costs.

Changes in group membership

When it comes to health insurance, insurers calculate premiums based on the risk profile of your group. As your team evolves, so does its risk profile. So, changes in your group membership can affect your rates because they influence the perceived risk and, consequently, the cost of your policy.

Size

Larger groups often have more predictable claim patterns. The larger the group, the lower the per-person cost of insurance. This is due to risk pooling, where the insurer can spread the risk of claims across a larger number of individuals.

If your workforce decreased in the previous year, you may have to pay a higher rate when the renewal period comes around. And, if you have a small group with a high number of claims, you will likely see a significant increase in premiums at renewal.

Age

If the average age of your group has risen since the last renewal, there’s a chance this might contribute to higher renewal rates.

Health status

Insurers assess the overall health of your group to predict potential healthcare costs. If members of your group have developed serious or chronic health conditions since the last renewal, it could lead to higher renewal rates.

However, the impact of health status on renewal rates can vary depending on the size of your group and the type of plan you have. In larger groups, the health status of individual members has less impact on the overall group rate because the risk is spread out over more people. For smaller groups, the health status of even one or two members can significantly affect the group’s renewal rates.

New dependents

Dependents — such as spouses and children — increase the number of individuals covered under your plan. Each dependent has their own health risks and needs that contribute to the overall cost of the plan, and this can potentially increase the overall risk from the insurance company’s perspective.

If the dependents are generally healthy, the impact on your renewal rates might be minimal. If the dependents have significant health issues or require frequent medical care, your renewal rates could increase because the insurer anticipates that these dependents will likely generate higher healthcare costs.

Industry trends

Several industry trends can significantly impact group health insurance renewal rates. Healthcare inflation — the increase in healthcare costs over time — is one key trend that affects even groups with low claims. As healthcare becomes more expensive, insurance companies may increase premiums to cover these higher costs.

Another trend is the shift towards value-based care, personalized medicine, and advanced treatment. These developments can lead to improved health outcomes and often lower costs.

Regulatory changes

Regulatory changes and reforms in the healthcare sector can also impact renewal rates. Changes in laws or regulations could affect coverage requirements or increase the pricing of health insurance plans.

How to navigate the renewal process for your business

Navigating the health insurance renewal process can be challenging, but it can be smooth and successful if you tackle it with the right knowledge and strategy. Consider these steps to guide you through the process.

Review your current plan

Start by reviewing your current plan to understand its:

• Coverage
• Benefits
• Costs
• Overall suitability for your group’s needs

This will help you identify what’s working and what needs to change.

Review the renewal offer

When you receive the renewal offer from your insurance company, assess it carefully. Compare the new terms with your current plan and consider how they align with your needs and budget.

Explore alternatives

Don’t limit yourself to the renewal offer. Explore alternatives from other insurance providers. Each type of plan comes with its own set of advantages and disadvantages, so you must consider your business’s specific needs and circumstances when exploring these alternatives, which include:

• Fully insured plans
• Self-insured plans
• Level-funded plans
• Pooled plans

Fully insured plans

These are traditional insurance plans where the insurance company assumes the risk of providing health coverage in exchange for premiums. They’re regulated by state laws and can be more expensive, but their costs are also more predictable.

Self-insured plans

With self-insured or self-funded health plans, you assume the risk of providing health coverage. While these plans can lead to cost savings in years with low claims, they also expose your businesses to potentially high costs in years with high claims.

Level-funded plans

Level-funded plans are a hybrid of fully insured and self-insured plans. They offer more flexibility and potential cost savings while limiting the risk to you. Modern insurance companies like Sana offer level-funded plans that can be a great fit for small and medium-sized businesses with five to 300 employees.

Pooled plans

You can also take advantage of Professional Employer Organization (PEO) plans and Association Health Plans (AHPs).

PEOs provide insurance by pooling together small businesses to get better rates. They share responsibilities with your business, acting as a co-employer to handle several aspects of the business:

• Benefits administration
• Human resources
• Payroll
• Administrative support

You retain managerial jurisdiction and make all decisions regarding your human capital.

AHPs allow small businesses and self-employed individuals to band together to create a group health plan. While both types of plans offer cost savings, they also limit your ability to customize your plan to your specific needs.

Make a decision

After assessing the renewal offer and exploring alternatives, make a decision. Choose the plan that best meets your needs and budget.

Communicate with your employees

Once you’ve made a decision, communicate the changes to your employees through a company-wide email or letter or your benefits administration platform. Make sure they understand the new plan and how it affects them.

Conduct the employee enrollment process

Conduct the enrollment process to get your employees signed up for the new plan. Make sure to provide support and answer any questions they may have.

Benefits administration software can make benefits administration as simple as filling out a few forms and clicking a few buttons. It can also include a knowledge base or chatbot that answers employee questions to streamline and simplify the entire enrollment process.

Implement the policy

Once enrollment is complete, implement the policy by setting up the necessary systems and processes.

Continue to manage your policy

Plan renewal doesn’t end with implementation. You must continue to manage your policy throughout the year. This includes handling claims, addressing issues, and ensuring the plan continues to meet your needs.

Stay compliant with regulations

Finally, ensure you stay compliant with all relevant health insurance regulations. This can help you avoid penalties and ensure your policy remains valid.

Health insurance renewal FAQs

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