Good self-funded Plan reporting answers six questions every month: what you paid, what you owe but haven’t paid, how that compares to budget, which claims are driving it, who’s covered, and what’s coming. If your package doesn’t answer all six, you’re running a self-funded Plan on a lagging indicator.

Most employers now carry this risk directly. KFF’s 2026 Employer Health Benefits Survey found that 71% of covered workers are in self-funded plans, including 85% at firms with 200 or more workers. Average family premiums reached $28,303 in 2026, up 5% over 2025, and covered workers contributed $7,471 of that themselves. When you self-fund, those dollars stop being a fixed premium and become a variable claims line.

That makes the monthly reporting package the most consequential document your TPA sends you, and the one most employers read least closely. Here’s what a good one contains, and what each number is actually telling you.

What should self-funded Plan reporting tell you every month?

A monthly package should give you six numbers: paid claims PEPM, fixed costs PEPM, IBNR, performance against your funding rate, large claim activity measured against your Specific Deductible, and enrollment. Each answers a different question. Together they tell you whether the Plan is on track and where the pressure is coming from.

• Paid claims PEPM, with medical and pharmacy shown separately
• Fixed costs PEPM, covering administration, stop loss premium, and vendor fees
• IBNR, with the method behind the estimate stated
• Performance against your funding rate, for the month and YTD
• Large claim activity measured against your Specific Deductible
• Enrollment by tier, with the prior month shown alongside

Anything beyond those six is useful. Anything short of them leaves you guessing. If you’re still deciding whether self-funding fits your organization at all, start with what self-funded actually means before you worry about the reporting that comes with it.

Why is PEPM the number to watch instead of total spend?

PEPM is cost per employee per month: total Plan cost divided by covered employees divided by the months in the period. It holds enrollment constant, so a rise in PEPM means cost per person is genuinely rising. Total spend climbs when you hire, which tells you about headcount rather than about the Plan.

Report PMPM alongside it. PMPM is cost per member per month, counting dependents, and the gap between the two numbers is where tier migration shows up. Carry both to two decimals.

Split medical and pharmacy. The two move on different drivers, and a blended PEPM can hide a specialty drug problem until it’s large enough to reprice your stop loss. If your package reports one combined number, ask for the split now rather than during renewal.

What does IBNR change about the number you budget to?

IBNR is the Plan’s estimate of care that has already happened but hasn’t reached the claims system yet. Paid claims tell you what left the bank account. Paid claims plus IBNR tell you what the period actually cost. Budget to the second number, because the first one always looks better.

Claims arrive late. A member is treated in October, the provider bills in November, and the claim pays in December. Paid claims reporting books that cost in December. Incurred reporting books it in October, where it belongs.

That lag makes a new Plan year look inexpensive. The opening months carry almost no run-out, so paid claims understate the real cost, sometimes badly. Budget to paid claims early and you’ll true up late, which is the worst time to find out.

Your package should state the IBNR method and the completion factors behind it, so the estimate can be questioned rather than simply accepted. Ask your consultant or actuary how it’s built and how often it’s revisited.

How should large claims and stop loss show up in your reporting?

Your package should show every claimant tracking toward your Specific Deductible, identified by member ID and condition, with paid to date and projected spend. Spending concentrates hard. EBRI found that 1% of enrollees in employment-based health plans accounted for 29% of spending. A few members decide your year.

The Specific Deductible is the dollar level at which your stop loss carrier begins reimbursing claims on a single member. Below it, the Plan pays. Above it, the carrier pays, subject to the contract terms.

A useful large claim report lists each tracking member by member ID and condition, never by name, with paid to date, projected spend, and the status of any reimbursement already filed. It should also flag members approaching half of your Specific Deductible, because those are the ones that become next year’s laser conversation.

If your report shows only the claimants who’ve already breached the Specific Deductible, it’s a historical document. The value sits with the ones on the way there.

What does your loss ratio tell you, and what does it hide?

Loss ratio compares claims to funding, expressed as a percentage. It tells you whether the Plan is running inside what you set aside. It hides timing, so a loss ratio built on paid claims alone early in a Plan year will understate what that year is actually costing you.

Run it on a rolling full year rather than month by month. A single month swings on one claim and tells you very little. Run it on incurred claims rather than paid, or you’re reading the lag instead of the Plan.

A loss ratio under your funding rate isn’t automatically good news. It can mean the Plan had a quiet year that won’t repeat, or it can mean your funding rate is set too high and cash is sitting still. The ratio raises the question. The claims detail answers it, and so do the levers available to you.

What should your HR team be able to do with the same report?

The same package should be readable by the person fielding employee questions, not only by finance. An HR Manager should be able to open it and see utilization by category, where members are going for care, and which vendor programs are actually being used, without building a spreadsheet first.

HR answers the questions the numbers generate. If the report shows emergency room use climbing, HR is the team building the communication that redirects it. If making the report readable takes two hours and a pivot table, that communication doesn’t get built.

Reporting earns its keep only when somebody acts on it. Totem’s published results include a range of 8% to 29% in medical spend savings, and that range comes from acting on what the reporting shows rather than from the reporting itself.

Talk to someone who reads these for a living

If your current package doesn’t answer these six questions, that’s worth a conversation well before your next renewal. Totem is a fee-only, carrier-independent benefits consulting firm, and our published Net Promoter Score is 86. We’ll look at what you’re receiving today and tell you plainly what’s missing. Be There for Everyone.

 

FAQ

Frequently asked questions

What is PEPM in self-funded Plan reporting?

PEPM is cost per employee per month: total Plan cost divided by covered employees divided by the months in the period. It’s the standard way to compare Plan cost across periods while enrollment is changing. Report it to two decimals, with medical and pharmacy shown separately.

What’s the difference between paid claims and incurred claims?

Paid claims are what the Plan actually disbursed during a period. Incurred claims are what the Plan owes for care delivered in that period, whether or not the claim has arrived yet. The gap between the two is IBNR, and it’s widest in the opening months of a Plan year.

How often should a self-funded employer receive Plan reporting?

Monthly, with a deeper review each quarter and a full review ahead of renewal. Monthly reporting catches a trend while there’s still time to respond to it. Quarterly and annual reporting mostly tells you what already happened.

What should an employer do if the reporting package is thin?

Ask the TPA which reports exist beyond the standard package, since many produce more than they routinely send. Then bring the remaining gaps to renewal, when you have the most leverage to get them added.

 

This post is general information about Plan reporting practice. It isn’t legal, tax, actuarial, or fiduciary advice. For how any of it applies to your Plan, talk to your Totem consultant or your own counsel.