OneVillage — Who's Who in Health Benefits

The one idea

Every organization in health benefits does one of three jobs: it pays for care, it delivers care, or it helps an employer buy and run benefits. Name the job first, then the category. Most confusion, in a meeting or in HubSpot, comes from skipping that step.

Pays for care

Health plans: medical payers such as UnitedHealthcare, Cigna, Aetna and CareFirst.

Carriers: insurers for life, disability, dental, vision and supplemental coverage.

The employer itself, when the plan is self-funded.

Delivers care

Health systems: hospitals, physician groups and academic medical centers.

Clinicians who bill for their work code by code, at fee-schedule rates.

They are the ones who get paid by the payers.

Helps buy and run benefits

Brokers and consultants advise the employer and run the vendor search.

PEOs sponsor one benefits program for many small employers.

TPAs process claims, PBMs run pharmacy, EAPs provide short-term counseling.

Health plan versus carrier

	Health plan	Carrier
What it is	A medical payer. It insures or administers medical coverage and pays doctor and hospital claims.	The broad benefits term for any insurer that carries a line of coverage: medical, dental, vision, life, disability or supplemental.
Examples	UnitedHealthcare, Cigna Healthcare, Aetna, CareFirst BCBS, Anthem Blue Cross Blue Shield, Elevance Health.	Principal, Unum, Prudential, Homesteaders Life, Dai-ichi Life.
Pays for doctor visits?	Yes. It decides what gets reimbursed.	Only if it is also a health plan. Life and disability carriers never do.
To OneVillage	A buyer: the audience for the health-plan pitch, and the payer behind billed clinical codes.	Mostly channel and partners: they bundle or refer services. They do not buy us for members' medical costs.

The rule: every health plan is a carrier, but most carriers are not health plans. When someone says "the carrier," ask one question back: medical, or ancillary?

Fully insured versus self-funded

This is the distinction that changes what a health plan is to the employer, and how our ROI story works. Ask it on the first call.

Fully insured

The employer pays a fixed premium to the health plan.
The health plan carries the claims risk and keeps what it saves.
Our ROI shows up as lower premium increases over time, not a direct dollar offset.

Self-funded

The employer pays claims out of its own money.
A health plan or a TPA only administers the plan (often called ASO, administrative services only).
Every avoided claim dollar is the employer's. This is where the 3.5x ROI model applies: headcount × PEPM × 12 × 3.5.

The administrators in the middle

These organizations run part of the benefits machine for someone else. None of them is our economic buyer, but each one can make a deal easier or harder.

Type	What it does	Why it matters to OneVillage
TPA	Third-party administrator. Processes and pays claims for a self-funded employer. Health plans run their own, such as UMR (UnitedHealthcare) and Meritain (Aetna).	The usual source of the claims feed that powers proactive outreach. Also a partner channel: one TPA serves many self-funded employers.
PBM	Pharmacy benefit manager. Runs the drug benefit: formulary, pharmacy network and pricing. Examples: Optum Rx, Express Scripts, CVS Caremark.	Not a buyer. Matters when a member's problem is a prescription denial or a prior authorization.
EAP	Employee assistance program. Short-term counseling and referral, often bundled into a life or disability carrier's contract.	Often the incumbent we sit beside or replace. Know what the client already gets free before you price against it.

PEPM versus PMPM. Employers buy us per employee per month (PEPM) and count employees. Health plans think per member per month (PMPM) and count every covered life, dependents included. Use the unit your buyer uses.

Health systems: the organizations that deliver care

Hospitals, physician groups and academic medical centers. They are paid by health plans and Medicare, code by code, under fee schedules. In HubSpot: CommonSpirit Health, Cedars-Sinai, Johns Hopkins Medicine and CHRISTUS Health.

A health system as a partner

A clinical or distribution partner, or a licensee of our platform and programs.
The conversation is about their patients, their clinicians and their revenue, not an employee benefit.

A health system as an employer

Health systems are also large employers buying benefits for their own staff.
The contact is HR, but the company is still a health system. Tag it Health System.

Same name, different company. Johns Hopkins Medicine is a health system; Johns Hopkins Health Plans is a health plan. Integrated organizations such as Kaiser Permanente are both under one roof. Tag the entity you are actually talking to.

The channel: brokers, consultants, PEOs and associations

Type	What it is	What it means for the deal
Broker or consultant	Advises the employer on its whole benefits package and runs the vendor search. Examples: OneDigital, Alliant, Hilb Group, Brown & Brown.	The influencer. They decide whether we get in the room. Run the deal through them, never around them.
PEO	Professional employer organization. Co-employs the staff of many small employers and sponsors one benefits program for all of them. Example: Insperity.	One agreement can reach many employers at once. The PEO, not each small employer, chooses the vendors.
Association	A trade or professional association, or a nonprofit advocacy organization.	Can be a client for its own staff, or a channel to its members.

PolicyHow the money moves: fee schedules and billing codes

Clinicians are paid per service, and each service has a billing code. Medicare sets the price of each code every year in the Physician Fee Schedule: a proposed rule in the summer, a final rule in November, effective January 1. Many commercial health plans set their rates relative to Medicare, so a CMS change often travels, although commercial coverage of new codes can lag.

CMS sets the code and price

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A clinician delivers the service

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The clinician bills the code

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Medicare or the health plan pays

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The rate follows the fee schedule

RTM: remote therapeutic monitoring

Pays clinicians, physical and occupational therapists included, to monitor a patient's therapy between visits.
The 2026 fee schedule added codes for 2 to 15 days of data in a month and a 10-minute management code, so shorter monitoring now gets paid.

PIN: principal illness navigation

Medicare codes G0023 and G0024 pay for navigating a patient through a serious, high-risk condition.
Delivered by navigators or community health workers working under a billing practitioner.

What a policy tailwind is

A finalized rule that widens what can be billed for work we already do or plan to do. RTM and PIN are tailwinds for OneVillage's payer-billed clinical programs. They do not change the employer PEPM, because employers do not bill Medicare. Employer-benefits navigation competitors sell on PEPM and bill no payer for navigation. The competitors that do bill payers are clinical oncology practices: Color bills health plans for its virtual cancer clinic, and Reimagine Care helps cancer centers bill care-management and monitoring codes. Billing PIN and RTM from inside an employer benefit is open ground for us. Policy-focused investors look for exactly this kind of opening.

Keep it accurate. A tailwind comes with requirements: a licensed billing clinician, patient consent, qualifying conditions or devices, and documentation. Medicare pays first; commercial plans may follow later or not at all.

Tagging it right in HubSpot

Tag by what the company is, not by the conversation you are having this week. Set the Customer Segment on both the contact and the company. Contacts created by the HubSpot BCC arrive blank, so set theirs by hand.

Segment	Use it for	Examples
Existing Customer	Employers with a live OneVillage contract.	Current clients
Direct Prospect	Employers we are selling to directly.	Open pipeline
Churned Customer	Former clients.	Lapsed contracts
Broker	Brokers and benefits consultants.	OneDigital, Brown & Brown
PEO	Professional employer organizations.	Insperity
Health Plan	Medical payers.	UnitedHealthcare, Cigna Healthcare, Aetna, CareFirst BCBS
Carrier	Life, disability, dental, vision and supplemental insurers.	Principal, Unum, Prudential
Health System	Hospitals, physician groups, academic medical centers.	CommonSpirit Health, Cedars-Sinai
EAP	Employee assistance program vendors.	EAP incumbents
Association / Advocacy Group	Trade and professional associations, advocacy groups.	Professional societies
Investor	Venture funds, angels, economic development investors.	Síol VC, TEDCO, Kalos Ventures
Member	Individual members who use OneVillage. Contacts only.	Program members
Other	Press, service providers and everyone else.	Washington Business Journal

Gray areas. Cigna Healthcare is a Health Plan; Cigna Ventures is an Investor. A client's medical carrier is a Health Plan even when it is simply the insurer behind our client's plan.

Check yourself

Before you tag a record or pitch an organization:

Does it pay for care, deliver care, or help an employer buy benefits?
If it is an insurer: medical, or ancillary?
Is the employer fully insured or self-funded?
Who administers the claims: the health plan or a TPA?
Is there a broker, consultant or PEO in the middle?
Are we pricing PEPM for an employer, or PMPM for a health plan?
Is the segment set on both the contact and the company?
Would a colleague pulling a health plan list want this record in it?

Bottom line

Pays for care, delivers care, or helps buy it: name the job, then the category. Every health plan is a carrier, most carriers are not health plans, and health systems are the ones who get paid. Fee schedules decide what they get paid for, which is why a policy change can open a market.

The teach-in PDF

The same module as a seven-page branded teach-in, for printing or for keeping open next to your HubSpot view.

📘 Who's Who in Health Benefits (PDF) ✏️ Take the Day-21 quiz in the portal

OneVillage Sales Enablement · Week 5 · Competitive Positioning · Questions: ashley@onevillage.io