Mike Roche:
One of my favorite analogies to use is a puzzle. So both fully insured and self-funding have all the same pieces. When you fully insure it, they come all put together. You do not have to worry about your third-party administrator, your pharmacy benefit manager, your network, your stop-loss vendor. That's all encompassed in one easy package. And you write a check every month, and you're ready to go. ... With self-funded — and it's important to have a really good consultant when you do this — you get to pick who all of those partners are. So you can find the network that fits your culture best. I want to tier my benefits and help my employees find value. I want a fully transparent PBM — my pharmacy benefit manager. I want to understand where my rebate's going, and am I getting the best price on these prescription drugs? I want a stop loss vendor that gives me credit for the things that I'm doing to help control costs. And I want a third-party administrator who is progressive and helps me control those dollars, making sure that they are paying.

...

We get the claim, we reprice it, whether if it's in network, and we send it off to the TPA. What the third party administrator does is adjudicate that claim based on their summary plan description, which is about that thick. They're the ones who make the determination to process as in accordance with the plan, or, this isn't covered. So if that happens, they work with — one, we'd start with the broker and have them help you figure out how to appeal that with the TPA.