A self-insured city pays medical claims as they come in, plus stop-loss. Telehealth ROI is PEPM cost versus avoided low-acuity claims, plus EMS savings only with a resident program. Keep observed TAP results separate from the model.
What does self-insured mean for a city?
The city or its benefit pool holds the insurance risk for employees and dependents. A third-party administrator pays bills; stop-loss covers catastrophic claims.
AHRQ’s Medical Expenditure Panel Survey Insurance Component tracks how employers fund coverage: large establishments are far more likely to self-insure at least one plan than small ones. See MEPS-IC (AHRQ, annual; 2023 tables). State and local governments often sit in that group even when the town feels small.
What is the $9 PEPM model?
TAP’s working model for a self-insured public employer is $9 per employee per month. The $9 is a model input, not an invoice and not a household utility rate.
Method:
- Put the $9 PEPM on the cost side for the enrolled population, as specified in the quote.
- On the savings side, count low-acuity visits that would have been an urgent-care or emergency-department claim.
- Do not count avoided 911 dispatches unless the city also funds a resident program and has CAD data. Employee-plan ROI and EMS ROI are different ledgers.
If a broker wants to blend the $9 into a fully insured rate, stop. The ROI only works when claims hit the city account.
Which savings are observed, and which are modeled?
Observed, TAP book of business: 93 percent of encounters resolved without another claim. Residents and employee-plan members rate the service 9.9/10. Ferris, Texas, a resident program, saw 20 percent fewer non-emergent EMS runs and more than 50 percent adoption, per City Manager Brooks Williams. That is not employee-plan ROI.
Modeled, EMS side: $450 to $900 per avoided non-emergency dispatch, using municipal cost-to-serve (crew, apparatus, and the emergency-department bill the city often does not collect). This line belongs on the fire/EMS budget, not the health-plan PEPM, unless you have a written allocation.
Modeled, plan side: avoided urgent-care and emergency-department allowed amounts, minus the $9 PEPM. Use your own TPA’s allowed amounts. National averages hide plan design.
CDC NHAMCS benchmarks how often emergency departments handle problems that are treated and released; see CDC NCHS Emergency Department FastStats. It supports the direction, not your claims file.
How should HR and finance build the one-page ROI?
- Population. Benefit-eligible employees (and dependents if enrolled). Do not mix in residents.
- Cost. $9 PEPM times enrolled lives times 12. Label it “modeled TAP PEPM.”
- Baseline. Twelve months of urgent-care and emergency-department claims under $2,000 allowed, from the TPA. Exclude trauma, chest pain, and other red-flag codes your medical director names.
- Substitution rate. Do not invent 50 percent. Start at 10 to 20 percent of the low-acuity bucket in year one, then swap in your own utilization after two quarters.
- Observed check. After two quarters, compare telehealth encounters, downstream claims within 7 days (TAP’s 93 percent is the reference, not your target), and member complaints.
HHS keeps a plain-language overview at telehealth.hhs.gov. Your TPA file, not that page, does the PEPM math.
What does this not buy?
- Does not replace stop-loss.
- Does not cover uninsured residents. That is a separate municipal program.
- Does not skip union or civil-service notice where a benefits change requires it.
- Does not need a clinic, a nurse on payroll, or a new FTE in benefits.
Employee plan or resident program?
| Self-insured employee telehealth | Resident municipal telehealth | |
|---|---|---|
| Buyer | HR / finance / pool | City manager / council / fire |
| Covered group | Employees and dependents | Households in the city |
| Primary ROI ledger | Medical claims + $9 PEPM (modeled) | EMS cost-to-serve + adoption |
| Proof to show | 93% resolved without another claim (observed) | Ferris 20% fewer non-emergent runs (observed) |
Some cities buy both. Keep the savings numbers separate.
What belongs in the benefits committee packet?
- The $9 PEPM, labeled as a model, next to a vendor quote
- Twelve months of low-acuity urgent-care and ED claims
- TAP’s 93 percent resolved-without-another-claim figure, labeled observed
- A sentence that Ferris is a resident EMS result, not an employee-plan result
- HIPAA and TPA data-sharing terms
TAP works with 780+ public-sector partners; self-insured cities are a subset. Ask for a quote built on your enrollment, not a neighbor’s rumor.
Ask for a plan-level estimate
Send enrollment and a year of low-acuity claims. TAP will return PEPM cost as a model and keep EMS dollars off the page unless you also run a resident program.
Request a self-insured PEPM estimate
Last reviewed: September 2026.
