Scanning sources…acquiring signal · establishing uplink
Why this matters: The Big-10 carriers (Cigna, Aetna, UHC, Humana, BCBS, Anthem…) are not comparable to our 282 employer-sponsored plans. In the majority of employer plans, the carrier is only the TPA — the employer bears the claim risk. This changes the regulator, the filings, the appeals path, and the data signal for every downstream analysis.
0
health_payer entities
0
employer-sponsored plans
0
across 282 plans
~65%
US covered workers in self-funded plans (KFF)
Side-by-Side Comparison Matrix
13 dimensions of meaningful difference| Dimension | Big-10 Carrier (fully-insured) | Employer-Sponsored Plan (self-funded) |
|---|---|---|
| Who bears claim risk | Carrier (fully-insured book) | Employer / trust (ASO, ~65% of covered workers) |
| Governing law | State insurance code + NAIC model laws | ERISA (DOL/IRS/PBGC); FEHBA or governmental regime for specific classes |
| Primary regulator | State DOI (rate & form) + CMS for MA/PDP | DOL EBSA · OPM (FEHB) · state legis. (gov) · LMRA §302 trustees (T-H) |
| Plan document | COC / EOC filed with state DOI | Plan Document + SPD (Summary Plan Description) + stop-loss contract |
| Annual filing | NAIC Annual Statement; Rate & Form filings | Form 5500 (DOL) — Schedules A, C, H |
| Appeals ladder | Internal → state external review (IRO) | ERISA §503 internal → federal court; OPM recon for FEHB |
| State mandate applicability | Fully subject to state benefit mandates | ERISA preempts state mandates (self-funded only) |
| Transparency in Coverage | Files MRF as the issuer | Files MRF as the plan; TPA typically produces it |
| Pharmacy benefit | Often owned PBM (OptumRx, Caremark, Express Scripts/Evernorth) | Commonly carved out to an independent PBM contract |
| Network | Owned network; contracts directly with providers | Rents network from its TPA (e.g., UHC Choice Plus, Cigna PPO) |
| Stop-loss / reinsurance | Uses reinsurance treaties across lines | Buys specific + aggregate stop-loss to cap employer risk |
| Member universe | Open enrollment book (group + individual + exchange) | Closed to eligible employees + dependents |
| Source of truth in Panopticon | entity_subtype = health_payer | entity_type = health_plan, entity_subtype = employer_sponsored |
ERISA
Private-sector self-funded
reg: DOL/IRS/PBGC
preempts: State insurance law
FEHBA
Federal employee plans
reg: OPM
preempts: State & ERISA
Governmental
State, county, muni, public higher-ed
reg: State legislature
preempts: ERISA-exempt (GASB 74/75)
Taft-Hartley
Multiemployer union trusts
reg: DOL + LMRA §302
preempts: State insurance law
TPA Cross-Walk
How many of the 282 ESI plans each carrier administersNo TPA data loaded yet.
Built from the offered_by relationship (plan → TPA carrier entity) + metadata_json.tpa.
Insurance Carriers
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Employer-Sponsored Plans
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Carrier data via /api/payers; ESI plan data via /api/health/employer-plans. Both ledgers are fully sortable and filterable. Click a row to open its dossier in-pane. The 65% self-funded figure is from the KFF 2024 Employer Health Benefits Survey.