Direct contracting for self-funded employers: a launch checklist

By HealthMe · Last updated November 1, 2026.

A direct provider contract becomes useful when members can find it, the practice can act on it, and the plan can pay and record it correctly. Use this checklist to turn an agreement into a working care pathway.

1. Define the population and opportunity

Start with employee locations, covered dependents, existing provider relationships, and actual plan spending. Identify services that members can reasonably access and schedule. Distinguish projected savings from observed results, and include the full program cost in the model.

2. Agree on the purchase

For each provider or package, document the services, prices, exclusions, participating facilities, and effective dates. Establish how additional services are approved, how member billing is handled, and which party funds payment. Identify the contacts for clinical coordination and administrative questions.

3. Align the plan and partner documents

Work with counsel, the TPA, and the broker to identify necessary plan amendments and participant communications. Address eligibility, covered services, direct-provider access, authorization, cost-sharing, claims, and appeals. Confirm the applicable SPD, modification notice, and benefit-summary requirements. DOL’s group health plan guide explains the role of plan documents and participant disclosures.

A mid-year launch is a plan-specific decision, not an automatic feature of direct contracting. Establish the effective date only after the responsible teams confirm readiness.

4. Resolve HSA and stop-loss questions

If the program serves HSA-qualified plans, have the benefits team review any reduced-cost or zero-cost incentive before announcing it. The use of a direct contract does not itself create an exception to deductible rules. Review IRS Publication 969.

Separately, obtain written stop-loss review of the arrangement and any required endorsement. Do not assume that a provider agreement changes the insurance policy. Use the stop-loss review guide.

5. Test the operational workflow

• Verify member eligibility and any required authorization.
• Confirm the provider can identify the program and schedule the service.
• Validate the TPA’s payment, claim or encounter, and accumulator process.
• Check that duplicate billing or repricing will not occur.
• Assign owners for funding, reconciliation, and exceptions.

6. Give members one clear next step

Explain who the program is for, how to reach navigation, which costs are known, and what approval is needed. Tell members whom to contact before purchasing care or scheduling outside the program. Give front-desk teams the same instructions.

7. Measure the complete experience

Track access, completed episodes, member feedback, payment timeliness, and comparable plan costs. Review cases that did not proceed as well as those that did. Savings estimates improve when the team can connect a quoted price to a completed, paid episode.

HealthMe can support a private direct-contract network and the navigation workflow that makes it usable.

Start with What is direct specialty care? for the full model comparison, episode example, and FAQs.