Reference-Based Pricing Plans | Ascend Benefits Consulting Group

Understanding RBP

What Is Reference-Based Pricing?

Traditional PPO plans start with an inflated chargemaster price and negotiate a "discount." RBP flips this entirely — starting at a fair, transparent Medicare-based benchmark and building up from there.

67%

Average discount off billed
charges in Tennessee

The PPO Pricing Model

Your insurer negotiates a "discount" off whatever price a hospital sets. That original chargemaster price is often 400–500% of what Medicare pays. Even after the discount, you're paying far more than necessary — with no visibility into why.

The RBP Pricing Model

Providers are reimbursed based on a fair multiple of Medicare reimbursement rates — typically 130–150% depending on the service type. The benchmark is transparent, consistent, and verified. Providers get paid fairly — and employers pay significantly less.

Real-World Example: Knee Replacement (Trustmark Data)

What the Hospital Bills

$69,000

Billed / chargemaster rate

RBP Pays
$24,000
~135% of Medicare — fair & transparent

PPO Network Pays

$32,000

Discounted chargemaster price

Source: Trustmark Healthy Choices RBP Broker Toolkit (2025). Past performance may vary by group, plan design, and market.

Plan Options

Two Powerful Self-Funded Strategies

We offer both Level-Funded PPO plans and Reference-Based Pricing plans. Here's what each delivers for your business.

Level-Funded PPO Plans

Predictable payments, familiar networks, real savings potential

Most Familiar Starting Point

A Level-Funded PPO plan gives your business predictable fixed monthly payments while capturing the cost-saving potential of self-funding. Employees use the same major PPO networks they already know — UnitedHealth, Cigna, BCBS, Aetna, PHCS — with no disruption to how they access care.

Each month, you pay a set amount covering expected claims, stop-loss insurance, and administrative fees. If your group stays healthier than projected, the surplus can come back to you — unlike traditional insurance where the carrier keeps it all.

The Level-Funded PPO is the most familiar transition for groups coming off traditional group insurance. It delivers meaningful savings and transparency without asking employees to change how they find providers.

Familiar PPO networks — employees use the same doctors and hospitals

Predictable fixed monthly cost — no surprise invoices mid-year

Surplus refund potential — keep money when claims come in under budget

Stop-loss protection — caps your exposure on high-cost claims

Claims data transparency — know what's driving costs before renewal

Network restrictions still apply — in/out-of-network cost differences remain

Reference-Based Pricing Plans

Maximum savings, transparent pricing, true provider freedom

Greatest Cost Reduction

Reference-Based Pricing takes self-funding one step further by replacing PPO network rates with a transparent Medicare-based benchmark. Instead of paying a discounted percentage of an inflated chargemaster price, your plan pays providers a fair, verified amount — typically 130–150% of Medicare rates.

Because RBP is non-network, employees can see any licensed provider in the country without worrying about in/out-of-network penalties. No network limitations. No referral requirements. No surprises based on which hospital they choose.

Plans are backed by dedicated advocacy teams — Trustmark's Trusted Member Care or Imagine360's concierge support — who handle any provider billing questions. Fewer than 2% of claims result in balance bills, and 90% are resolved within two business days.

Up to 30% savings vs. PPO plans — driven by Medicare-based reimbursement

See any provider, anywhere — zero network restrictions in the U.S.

Full pricing transparency — clear, consistent benchmark tied to Medicare

5%+ lower claims trend year over year — sustainable savings, not a one-year deal

Balance bill protection — advocacy team resolves issues; employees pay nothing beyond normal cost-share

Requires member education upfront — employees need to understand how it differs from a PPO

Tennessee Market Data

How RBP Performs in Tennessee

Tennessee earns a 9 out of 10 RBP Score from Trustmark — one of the strongest markets in the country for RBP adoption and savings.

9/10

Tennessee RBP Score

1.1%

Statewide Appeal Rate

67.7%

Avg. Discount Off Billed

–12.4%

Rate Advantage vs. PPO

Market	RBP Score	Appeal Rate	Discount Off Billed	Rate Advantage vs. PPO	Active Groups
TN – Knoxville	10	0.0%	56.4%	–10.1%	10
TN – Memphis	10	0.4%	61.4%	–10.1%	10
TN – Nashville	9	1.6%	69.2%	–15.5%	16
TN – Chattanooga	8	2.0%	78.4%	–12.6%	10
TN – Tri-Cities	—	0.0%	70.5%	–14.3%	1
TN – Rural	—	0.0%	45.1%	–12.0%	2
Tennessee Overall	9/10	1.1%	67.7%	–12.4%	49

Source: Trustmark Healthy Choices RBP State Insights. Data based on plan experience 8/1/2022 – 6/30/2025. Past performance may not be indicative of future results. RBP Rate Advantage represents estimated premium rate reduction relative to Trustmark's lowest-cost national network plan. Actual advantages vary by census, plan design, and other factors.

Side-by-Side Comparison

Level-Funded PPO vs. Reference-Based Pricing

See how these two self-funded strategies compare across the factors that matter most to your business and your employees.

Feature	Level-Funded PPO	Reference-Based Pricing
Plan structure	Self-funded with fixed monthly payments	Self-funded with Medicare-based reimbursement
Provider access	In-network PPO (UHC, Cigna, BCBS, Aetna, PHCS)	✓ Any licensed provider in the U.S. — no network
Pricing benchmark	Discounted chargemaster / PPO contracted rates	Transparent Medicare-based rates (avg. 135%)
Potential savings vs. traditional	Up to 20–25%	Up to 30%
Claims data transparency	✓	✓
Surplus refund if claims are low	✓	✓
Stop-loss protection	✓	✓
In/out-of-network cost differences	Yes — apply to out-of-network use	✓ No — single cost-share structure
Balance billing risk	Minimal — PPO contracts eliminate most balance bills	Rare (<2% of claims) — advocacy team resolves fast
Employee education required	✓ Minimal — familiar PPO experience	Yes — upfront education recommended
Long-term claims trend	Depends on PPO network efficiency	5%+ lower trend vs. PPO (Trustmark data)
Best fit for	Groups transitioning from traditional insurance; employees who want familiar network access	Groups open to change; employers focused on maximum long-term cost reduction

Common Questions

Clearing Up the Myths About RBP

Hesitation about RBP is common — and mostly based on outdated concerns. Here's what the data actually shows.

✗"RBP is only for large employers."

✓Trustmark's Healthy Choices plan works for groups as small as 5 employees. Many small Tennessee businesses are saving with RBP right now.

✗"Providers won't accept RBP plans."

✓Most providers accept RBP, especially when supported by a TPA that actively educates providers about how the plan works and how they get paid.

✗"Employees will always get balance bills."

✓Fewer than 2% of claims result in balance bills. Of those, 90%+ are resolved within two business days — and employees are never responsible for paying them.

✗"RBP plans have worse coverage than PPOs."

✓RBP plans can be just as rich as PPOs — often with lower deductibles and a single out-of-pocket maximum, since there's no separate in/out-of-network structure.

✗"Costs are unpredictable for employers."

✓Reimbursements are tied to a transparent Medicare benchmark — giving employers far more pricing visibility than a PPO, where contracted rates can vary wildly for the same service.

✗"RBP is a new, unproven model."

✓RBP has been in use for over a decade. North Carolina moved its entire state employee health plan to RBP. Trustmark has nearly 10 years of RBP data; Imagine360 has 18+ years.

Our Approach

Is RBP the Right Fit for Your Business?

Business consultant reviewing plan options

9/10

Tennessee RBP Score —
one of the best markets in the U.S.

RBP isn't the right choice for every employer — and we'll tell you honestly when it's not. Our job is to find the strategy that delivers the best outcome for your specific group.

We offer RBP through two industry-leading carriers — Trustmark Healthy Choices (groups as small as 5 employees) and Imagine360 (100+ employees) — and we'll help you determine which makes the most sense for your workforce.

Are premiums rising unsustainably?

If you've seen year-over-year increases with no ability to benefit from a healthy group, RBP is worth a serious look.

Do you value pricing transparency?

Employers who want to understand exactly what they're paying for — and why — are strong RBP candidates.

Is your group between 5 and 150+ employees?

Trustmark works for groups as small as 5. Imagine360 is designed for groups of 100 or more.

Is your market a good fit?

Tennessee scores 9 out of 10 on Trustmark's RBP Market Score. Nashville, Knoxville, Memphis, and Chattanooga all score 8 or above.

Is your team open to a new approach?

RBP requires some upfront employee education. Both carriers provide robust onboarding resources — and we walk your team through everything before day one.

Stop Paying Inflated Rates.
Start Paying What's Fair.

What Is Reference-Based Pricing?

The PPO Pricing Model

The RBP Pricing Model

Real-World Example: Knee Replacement (Trustmark Data)

Two Powerful Self-Funded Strategies

How RBP Performs in Tennessee

Level-Funded PPO vs. Reference-Based Pricing

Clearing Up the Myths About RBP

Is RBP the Right Fit for Your Business?

Are premiums rising unsustainably?

Do you value pricing transparency?

Is your group between 5 and 150+ employees?

Is your market a good fit?

Is your team open to a new approach?

Ready to See What RBP Could Save Your Business?

Stop Paying Inflated Rates.Start Paying What's Fair.

What Is Reference-Based Pricing?

The PPO Pricing Model

The RBP Pricing Model

Real-World Example: Knee Replacement (Trustmark Data)

Two Powerful Self-Funded Strategies

How RBP Performs in Tennessee

Level-Funded PPO vs. Reference-Based Pricing

Clearing Up the Myths About RBP

Is RBP the Right Fit for Your Business?

Are premiums rising unsustainably?

Do you value pricing transparency?

Is your group between 5 and 150+ employees?

Is your market a good fit?

Is your team open to a new approach?

Ready to See What RBP Could Save Your Business?

Stop Paying Inflated Rates.
Start Paying What's Fair.