The book
Behind the Premium
A former underwriter's guide to what your health plan really costs. Eighteen short chapters that take one piece of the machine at a time, explain how it actually works, and end with the questions to ask at your next renewal.
Why I wrote it
"Most employers are making one of the biggest decisions on their P&L with less information than everyone else at the table. The carrier knows the numbers. The PBM knows the numbers. In a lot of cases the broker knows how they get paid and you do not. The CFO who signs off on the renewal is often the only person in the room who is guessing."
I started out as a math major, then spent years as an underwriter at Cigna deciding what groups were going to cost. From there I moved into existing business sales, then worked at one of the largest national brokerages in the country before starting Trinity Risk Partners.
None of what is in this book is complicated once someone lays it out. Nobody has much incentive to lay it out. So each chapter gives you the good and the bad of each option, because there is no one right answer for everyone. A 60 person engineering firm and a 450 person PE-backed manufacturer need different things. What I can do is hand you the strategy, so you can make the call yourself.
Whether you ever work with me or not, ask the questions at the end of each chapter at your next renewal. Underwriters, PBMs, and brokers all behave differently when they know the person across the table understands the game.
Dom Aiello, Founder, Trinity Risk Partners
What is inside
Eighteen chapters, one piece of the machine at a time.
- How insurance networks really workWhy a 60 percent discount tells you little, and why Medicare is the yardstick. Read the short answer
- How PBMs workRebates, aggregators, formularies, and where the money actually goes. Read the short answer
- Traditional carriers vs TPAsBundled carrier ASO against an unbundled independent TPA. Read the short answer
- How underwriters price your groupTrend, credibility, pooling, retention, and the discretion in between. Read the short answer
- Funding arrangementsFully insured, level funded, self-funded, and captive, side by side. Read the short answer
- Stop loss, demystifiedSpecific, aggregate, contract basis, lasers, and the riders worth buying. Read the short answer
- ICHRA and CHOICE strategiesFixed-cost allowances, classes, and where they fit. Read the short answer
- Direct contracting and direct primary careBundled case rates, centers of excellence, and DPC. Read the short answer
- Site of care navigation programsSame procedure, different building, very different price. Read the short answer
- Specialty drugs, GLP-1s, and gene therapyThe handful of claims that now drive the plan. Read the short answer
- Your claims data is an assetThe five parts of the Risk Analysis Plan and what they find. Read the short answer
- Employee retention statistics and strategiesWhat employees value, and building a plan that competes. Read the short answer
- Enrollment and communicationWhy enrollment falls flat, and what works instead. Read the short answer
- How your broker gets paidPercent of premium, PEPM, flat fees, and the commissions nobody mentions. Read the short answer
- Your fiduciary dutyWhat the CAA changed, and what prudent looks like. Read the short answer
- Running a renewal the right wayThe 12-month calendar and the broker of record process. Read the short answer
- PE-backed companies and M&A transitionsDiligence, harmonizing plans, and the funding opportunity. Read the short answer
- Cities, counties, schools, churches, and pooled plansTML, TAC, TRS-ActiveCare, church plans, and a fair comparison. Read the short answer
Who it is for
The person signing the renewal.
CFOs, owners, and HR directors at companies of every size. It is also written for the situations where the standard advice falls short: cities, counties, school districts, and churches on statewide pools, and PE-backed companies working through acquisitions.
You do not need an insurance background. You need about an hour, and your current renewal next to you.
Sources were checked as of October 16, 2026. General information for employers, not legal, tax, or benefits advice.
Contact
Want the book walked through against your plan?
Send me your renewal and I will show you which chapters matter most for your numbers.
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