Menopause support has rapidly shifted from a taboo topic to a fast-growing area of interest in an employer’s benefits offering, driven by workforce demographics, productivity risk, and a wave of specialized digital health platforms.

Menopause impacts most women between the ages of 40 and 58. Symptoms may range from hot flashes, joint pain, headaches, and fatigue to anxiety, insomnia, brain fog, and memory lapses. Women facing these challenges make up a significant portion of the workforce, with women aged 45 to 64 accounting for approximately 17.5% of the workforce according to the Department of Labor. Women going through perimenopause or menopause often experience these symptoms without support options from their employer, leading to missed workdays and loss of productivity at what may be a pivotal time in a person’s career. Studies estimate that menopause-related symptoms cost employers billions annually due to lost productivity and absenteeism, with many employees reporting reduced performance or considering leaving the workforce altogether.¹ Recent analysis from Forbes further emphasizes that organizations supporting employees through menopause may see improved retention, engagement, productivity, and overall workforce wellbeing, reinforcing menopause support as both a health and business strategy.²

Support for women going through menopause may take several forms.

• Menopause Leave or Time Off Programs: Employers are beginning to explore and launch designated time off programs for employees needing time away from work due to symptoms related to menopause that may not be covered or recognized under other leave policies. Recent developments also highlight the growing momentum behind menopause workplace accommodations. For example, Hone Health recently launched its “Menopause Time Off (MTO)” initiative, advocating for menopause-inclusive leave policies and workplace flexibility.³
• Telehealth with Menopause-Trained Clinicians: In today’s healthcare landscape, many individuals face fragmented care across primary care, mental health, and OB-GYN providers. Traditional care models often lack specialized menopause training, leading to underdiagnosis or undertreatment. Telehealth programs may assist in bridging this gap by providing holistic care plans designed specifically for the individual. Employers can access menopause support either through standalone point solutions (e.g., Midi Health) or through enhancements within existing medical or telehealth offerings. It is important to note that some solutions may already be covered under current insurance plans. Telehealth does not need to focus only on establishing care plans. These services may also expand to prescription treatment, virtual physical therapy, mental health support, and additional specialized services.
• Inclusion of Hormone Therapy in Medical Plans: Menopause Hormone Therapy (MHT) can be a beneficial approach for treating common symptoms of menopause such as hot flashes and bone loss. Hormone therapy should be tailored to each individual’s needs. Insurance typically covers FDA-approved formulations, but the specifics of the plan will dictate how much an employee will pay and the exact requirements for coverage. Patient assistance programs may also help individuals cover the cost of non-covered services or prescriptions.
• Education, Community, and Peer Support: Additional support programs may also benefit women facing the challenges associated with menopause. While standalone programs are beginning to expand, support may already be available to employees through existing programs such as EAPs or mental health benefits. In addition, organizations such as the Menopause Education Center focus entirely on educating employers and their workforce and helping organizations build a workplace-friendly menopause strategy. Efforts should also focus on reducing stigma around menopause and training front-line managers on when to direct employees to designated resources.

As employers have invested heavily in fertility and family-building benefits, menopause is emerging as the next frontier in women’s health equity. While the adoption of menopause-focused benefits is still in its early stages, the expansion of these programs is expected to accelerate rapidly.

Employers evaluating menopause benefits should take several steps:

1. Audit current benefit offerings (EAP, telehealth, medical coverage, leave programs)
2. Identify gaps in clinical and emotional support
3. Define a preferred strategy (enhance current offerings or implement a standalone solution)
4. Pilot or phase implementation of the preferred solution
5. Communicate resources clearly to employees

The first step should be to understand what benefits already exist that support women going through this period of life and communicate those benefits effectively to employees, underlining the employer’s commitment to a holistic benefits program. If additional support is needed, employers should evaluate their broader strategy and work to implement solutions in coordination with preferred partners.

Overall, employers should consider the real impact menopause may have on employees and business operations. Building upon existing benefits offerings can support attraction and retention efforts, strengthen equity and inclusion initiatives, and serve as an important component of a holistic employee benefits strategy.

¹Department of Labor workforce demographic data and various studies on menopause-related productivity and absenteeism trends in the workplace.
²Michelle Travis, “The Business Case for Supporting Employees Through Menopause,” Forbes, June 4, 2024.
https://www.forbes.com/sites/michelletravis/2024/06/04/the-business-case-for-supporting-employees-through-menopause/
³Hone Health, “Hone Health Launches Menopause Time Off (MTO).”
https://honehealth.com/edge/hone-health-launches-menopause-time-off-mto/

Implications for Cost, Care Quality, and Employee Engagement

At-home diagnostic testing has shifted from a convenience to a standard part of healthcare delivery. Accelerated by COVID-19 and advances in digital health, home diagnostics now include infectious disease testing, chronic condition monitoring, cancer screening, fertility, and genetics. For employers and plan fiduciaries, the focus is no longer whether these tools will remain relevant, but how to use them effectively to improve outcomes, manage costs, and avoid overutilization.

Evidence shows that evidence-based home tests can increase preventive screening rates, improve chronic disease management, expand access to care, and reduce downstream medical costs. However, poorly managed use can lead to false positives, unnecessary follow-up care, employee anxiety, and increased spending.

This article examines where home diagnostics provide value, where caution is needed, and how employers, carriers, and TPAs should approach coverage and employee engagement.

The Current Landscape

Home diagnostics are not new. Pregnancy tests have been available since the late 1970s, but the COVID-19 pandemic normalized self-testing at scale. In early 2022, more than 40 million U.S. households used government-supplied at-home COVID-19 tests, with approximately one-third of households participating overall (CDC, 2023). Adoption was widespread, and access gaps narrowed across racial and ethnic groups.

Industry forecasts indicate continued growth. A 2025 global diagnostics survey found that more than 60% of experts expect 10% to 25% of diagnostic tests to be performed at home by 2035, with U.S. adoption expected to outpace Europe (Simon-Kucher, 2025). Growth is strongest in chronic disease monitoring, women’s health, infectious disease testing, and cardiovascular screening. Several categories of home diagnostics are already producing measurable results.

Cancer Screening

Mailed fecal immunochemical test (FIT) kits and FIT-DNA tests, such as Cologuard, improve screening adherence compared with office-based colonoscopy programs alone. A large Kaiser Permanente initiative that mailed annual FIT kits more than doubled screening rates, reduced colorectal cancer incidence by approximately 30%, and cut deaths by half while eliminating racial disparities in screening outcomes (Kaiser Permanente Division of Research, 2025). For employers, these outcomes may reduce catastrophic claims, support earlier intervention, and improve workforce health. Coverage of guideline-recommended home screening tests is considered high-value preventive care.

Infectious Disease Testing

At-home COVID-19 tests demonstrated the value of rapid, decentralized diagnostics. Similar models are now emerging for influenza, RSV, and combination respiratory panels. While home antigen tests are generally less sensitive than laboratory PCR testing, their speed and accessibility can improve real-world detection and support faster behavior changes, particularly when paired with telehealth follow-up.

Chronic Disease Monitoring

Home monitoring tools, including blood pressure monitors and continuous glucose monitors (CGMs), are associated with reductions in emergency visits, hospitalizations, and long-term complications for individuals managing hypertension and diabetes. These tools may be most effective for populations with low adherence to treatment plans or preventive care.

However, broad implementation across already compliant populations may increase plan costs without producing meaningful clinical improvement. Employers should evaluate where these tools are likely to generate measurable value rather than assuming universal deployment will reduce spending.

Direct-to-Consumer Genetic and Wellness Testing

Direct-to-consumer genetic tests and wellness panels present mixed value for employer-sponsored health plans. While FDA-authorized genetic health risk tests, including certain 23andMe reports, meet analytical standards, results are probabilistic rather than diagnostic and are often misunderstood without clinical guidance (FDA, 2017; Harvard Health, 2023).

False positives and ambiguous findings can increase employee anxiety and lead to unnecessary follow-up testing. Physicians have also raised concerns that repeated self-testing may contribute to a cycle of anxiety, confirmatory diagnostics, and low-value care (Becker’s Hospital Review, 2024). Without utilization controls and employee education, employer health plans may see higher laboratory and imaging costs rather than savings.

Employer Implications

Self-insured employers should view home diagnostic testing as one component of a broader population health and cost-management strategy. When implemented appropriately, these tools can support higher preventive screening rates, earlier disease detection, improved chronic disease management, and lower hospitalization and late-stage treatment costs.

The key is using employer-specific data to identify gaps in care within the covered population. When gaps exist, employers should encourage evidence-based screening tools that align with established clinical guidelines and produce measurable outcomes. High-value tests should be covered at low or no cost to members, with minimal barriers to follow-up care when additional screenings or diagnostics are required. Employers should also work with carriers, TPAs, and clinical partners to evaluate new opportunities regularly, as innovation in this space is advancing quickly and benefit strategies will need to adapt.

Home diagnostic testing should not be viewed as a fringe benefit or consumer trend. It is becoming part of the healthcare system. When integrated into a disciplined benefits strategy, these tools can improve employee experience and support long-term cost control. Without appropriate oversight, they can also increase unnecessary utilization and spending.

Sources:
– Centers for Disease Control and Prevention (CDC). Use of COVIDTests.gov At-Home Test Kits Among Adults, MMWR, 2023. https://www.cdc.gov/mmwr/volumes/72/wr/mm7201a4.htm
– Simon-Kucher. From Pandemic Spike to Permanent Shift: The Rise of At-Home Diagnostics, 2025. https://www.simon-kucher.com
– Kaiser Permanente Division of Research. Colorectal Cancer Screening Program Doubled Screening Rates and Halved Deaths, 2025. https://divisionofresearch.kaiserpermanente.org
– U.S. Food and Drug Administration (FDA). Information Regarding the OraQuick In-Home HIV Test.
https://www.fda.gov
– U.S. Food and Drug Administration (FDA). FDA Allows Marketing of First Direct-to-Consumer Genetic Health Risk Tests, 2017.
https://www.fda.gov/news-events/press-announcements/fda-allows-marketing-first-direct-consumer-tests-provide-genetic-risk-information-certain
– Wang et al. Trends in Continuous Glucose Monitor Use Among Adults With Diabetes, Journal of General Internal Medicine, 2024/2025.
– UW Medicine / JAMA Network Open. Steady Glucose Monitor Use Helps Blood Sugar Control, 2025.
https://newsroom.uw.edu
– Cappuccio et al. Blood Pressure Control by Home Monitoring: Meta-Analysis of Randomized Trials, BMJ.
https://www.bmj.com
– Harvard Health Publishing. At-Home Tests: Help or Hindrance?, 2023.
https://www.health.harvard.edu
– Becker’s Hospital Review. At-Home Tests Are Booming, but Physicians Have Concerns, 2024.
https://www.beckershospitalreview.com
– Deloitte Insights. The Diagnostics Industry of Tomorrow, 2023.
https://www2.deloitte.com/us/en/insights/industry/health-care/future-of-diagnostics.html

Pension risk transfer (PRT) strategies, particularly buy-ins and buy-outs, have become a cornerstone for organizations looking to reduce pension-related risk and expense. Over the past several years, transaction volume has exceeded $45 billion annually, with recent activity surging in Q4 to $28 billion, driven by the largest quarter of buy-ins in US history.¹

On paper, the story is clear. Strong funding levels, favorable economic conditions, and a competitive insurance market have created the ideal environment for action.

But there is a more important question beneath the surface. Are organizations choosing the best strategy, or simply the most familiar one?

Although traditional insurance is common, simplicity should not be confused with efficiency.

The Hidden Trade-Off in Commercial Transactions

Commercial insurance solutions are built to generate profit. That reality is embedded in every transaction.

Pricing typically includes:

• Risk margins
• Capital charges
• Administrative costs
• Insurer profit

These are not minor line items. They are fundamental components of the structure. So while a buy-out may deliver a clean accounting outcome, it often comes at a premium that exceeds the true economic value of the obligation. In other words, organizations may be reducing risk, but they are also giving away value.

A Smarter Alternative: Captive Buy-Ins and Buy-Outs

A growing number of plan sponsors are rethinking the default by leveraging captive insurance companies to execute buy-ins and buy-outs. This approach shifts the equation. Instead of transferring both risk and economics to a third party, organizations can retain greater control while still achieving meaningful risk transfer.

Why Captives Change the Equation

Who Should Consider this Option?

The transaction can be structured in a myriad of ways that allows ultimate flexibility to plan sponsors while maximizing savings and financial stability. Frozen and accruing plans alike can take advantage of captive strategies. The real issue is not feasibility. It is that most organizations have only been shown one path.

Captive strategies introduce a more deliberate approach. One that reduces cost, preserves control, and aligns financial outcomes more closely with long-term objectives. For organizations willing to challenge convention, the opportunity is significant.

Start the Conversation

For organizations evaluating their PRT strategy, the path forward does not have to be limited to traditional options. The most effective approach starts with understanding the full range of what is possible and aligning that strategy with your financial and operational goals.

Spring Consulting Group has been at the forefront of designing and implementing captive-based PRT solutions, helping organizations move beyond one-size-fits-all transactions toward more efficient, controlled outcomes. If you are exploring your next step, now is the time to ask a different set of questions and consider whether your current approach is truly optimal. Connect with your Spring Consulting Group contact to continue the conversation.

¹LIMRA: U.S. Single Premium Pension Risk Transfer Product Sales Jump 132% in the Fourth Quarter of 2025 https://www.limra.com/en/newsroom/news-releases/2026/limra-u.s.-single-premium-pension-risk-transfer-product-sales-jump-132-in-the-fourth-quarter-of-2025

The Rise of Digital Payments

When a disability or paid leave claim is filed, it is rarely just an administrative transaction. It typically coincides with a moment of personal disruption, such as an illness, injury, parental bonding, caregiving event, or recovery period that temporarily removes an employee from work. In those moments, the timely delivery of income replacement benefits can be critical to financial stability, recovery, and trust in the system.

Expectations around how paid benefits are delivered are changing quickly. While job protection programs and unpaid leave often center on compliance and eligibility, income replacement programs introduce a different set of expectations. For disability insurance, paid family and medical leave, and other employer-sponsored wage replacement benefits, speed, certainty, and convenience are no longer viewed as enhancements. They are fundamental to the claimant experience.

As employees grow accustomed to real-time financial tools in their daily lives, traditional check-based processes and delayed disbursements can feel increasingly out of step with the purpose of paid leave and disability coverage. When benefits are intended to replace wages, delays can weaken the financial security these programs are designed to provide.

Digital disbursement options, such as direct bank transfers (ACH), push-to-card payments, and digital wallets, allow insurers to deliver funds within minutes. This shift reflects broader industry movement toward faster, more connected payment ecosystems.¹ This is not just about technical efficiency; it is about empathy. Research shows that 83 percent of consumers would consider switching carriers after a poor claims experience, reinforcing how central the payment moment has become to trust and retention.³

How it Impacts Employers

For employers, the modernization of claim payments is a critical component of workforce stability and administrative efficiency. When an employee is dealing with a claim, whether it is for workers’ compensation, disability, or personal property loss, their focus is split between recovery and financial obligations.

• Employee Financial Wellness: Delayed payments create unnecessary stress for employees. Faster access to funds allows them to settle medical bills or repair essential property sooner, helping them return to productive routines more quickly.
• Reduced HR Burden: Modern payment systems provide automated notifications and transparency. This significantly reduces the time HR and benefits teams spend acting as intermediaries or answering “Where is my check?” inquiries.
• Operational Resilience: During large-scale events or natural disasters, traditional mail can be disrupted for weeks. Digital payments ensure that benefits reach employees regardless of location or the state of local infrastructure.

What should Employers Do

Modernizing payment infrastructure should be viewed as an essential business strategy rather than a simple technology project. Broader financial system evolution is accelerating expectations for speed, connectivity, and flexibility across how money moves.²

To position your organization for success, consider the following steps:

• Adopt Digital Payment Technologies: Carriers should proactively embrace modern digital payment solutions—such as push‑to‑debit, real‑time payments (RTP), and other instant disbursement methods—by embedding these capabilities into their claims and payment workflows to improve speed, accuracy, and experience.
• Assess Carrier Payment Capabilities: When reviewing insurance partners, encourage employers to discuss and explore the payment capabilities currently available, including instant options such as push‑to‑debit or real‑time payments (RTP), in addition to standard ACH.
• Ensure Integration Readiness: Employers should confirm their HR and payroll systems can readily integrate with carrier claims and payment platforms—such as supporting API connectivity or standardized data feeds—so they can seamlessly receive claim and payment information once carriers deploy modern digital payment solutions.
• Educate Claimants Early: Set expectations by highlighting available digital payment options during claim intake and, where possible, in advance of filing a claim. Encouraging employees to select payment preferences early helps ensure timely, smooth delivery once benefits are approved.
• Prioritize Advanced Security: All stakeholders should work with IT and compliance teams to ensure platforms are protected by state‑of‑the‑art cybersecurity controls—such as strong encryption, multi‑factor authentication, and continuous monitoring—to safeguard employee financial data.

At its core, a claim is not just a reimbursement event. It is a test of how well an organization supports someone during disruption, where speed, clarity, and ease can either stabilize or intensify the experience.

The market is moving clearly toward faster, more connected, and expectation-driven payment ecosystems, while tolerance for delays and friction continues to decline. What was once an administrative step has become a defining moment in the customer relationship.

As a result, employers and carriers that modernize disbursement capabilities are not just improving efficiency. They are aligning with where the industry is heading and meeting expectations that are quickly becoming standard. In this environment, fast, reliable access to funds is no longer a differentiator. It is a baseline expectation and a reflection of trust, responsiveness, and credibility.

¹One Inc. 12 Insurance and Payments Trends Shaping 2025.
https://www.oneinc.com/resources/blog/12-insurance-and-payments-trends-shaping-2025
²PYMNTS. Banks Hire Chain Jugglers to Drive Cross-Chain Financial Services.
https://www.pymnts.com/blockchain/2026/banks-hire-chain-jugglers-to-drive-cross-chain-financial-services/
³InvoiceCloud. InvoiceCloud Research: 83% of Consumers Surveyed Would Switch Insurance Carriers After a Poor Claims Experience.
https://invoicecloud.net/press-room/invoicecloud-research-83-of-consumers-surveyed-would-switch-insurance-carriers-after-a-poor-claims-experience

Overview

The medical stop-loss market is experiencing significant upheaval as claim frequency and severity reach unprecedented levels. These developments have fundamentally altered the pricing landscape, with carriers adjusting their strategies in response to deteriorating loss ratios and mounting claim costs.

Rising Claims: Frequency and Severity

In 2025, claims well exceeded target loss ratios. The surge in stop-loss claims reflects broader trends in the healthcare market. Three primary factors are driving this increase: rising costs per medical service, higher incidence rates of severe diagnoses, and the introduction of expensive new treatments, drugs, and therapies. While these developments were anticipated given long-term healthcare cost trends, the magnitude and pace of change have exceeded many projections.

Cancer remains the dominant driver of stop-loss claims across the market, leading in both claimant count and total claim dollars. Cardiovascular conditions typically rank second, while newborn complications have emerged as a significant contributor, particularly for claims exceeding $1 million. Although cell and gene therapies have not yet been major contributors to historical claims, they represent a growing risk. The proliferation of these therapies is expected to further exacerbate both the frequency and severity of large claims in the coming years.

Reviewing data across our book of business and the broader industry reveals a significant acceleration in large-claim frequency across multiple threshold levels:

Claims exceeding $250,000 have grown substantially across the industry. Voya reported an 11% increase from 2023 to 2024¹. Spring’s internal data shows a more dramatic trajectory, with a 27% frequency increase from 2023 to 2024, followed by a 36% jump from 2024 to 2025 (a 72% cumulative increase from 2023 to 2025). In addition to increased frequency, severity rose by 21% on a per-claimant basis from 2023 to 2025, with total claim dollars for claims exceeding $250,000 increasing by 108% on a PEPM basis.

For claims above $500,000, the trend is equally concerning. TMHCC reported a 113% frequency increase from 2021 to 2024, including a 35% increase from 2023 to 2024 alone₂. Internal data reflects a 95% increase in frequency from 2023 to 2025 (36% from 2024 to 2025), coupled with a 29% increase in per-claimant severity over the same period (7% from 2024 to 2025). As a result, total claim dollars exceeding $500,000 surged by 152% from 2023 to 2025 (44% from 2024 to 2025).

At the $750,000 threshold, Voya documented a 15% frequency increase from 2023 to 2024¹. Internal analysis shows a 21% frequency increase from 2024 to 2025, along with a 26% severity increase over the same period. Total claim dollars above $750,000 rose by 52% from 2024 to 2025. Comparing 2023 to 2025, frequency increased by 115%, per-claimant severity increased by 45%, and total claim dollars increased by 190%.

Million-dollar claims present perhaps the most striking picture. Sun Life reported a 61% increase in frequency from 2021 to 2024, including a 29% increase from 2023 to 2024³. TMHCC reported a 113% frequency increase from 2021 to 2024, with a 35% rise from 2023 to 2024². QBE documented a 49% increase from 2021 to 2024 and a 32% increase from 2023 to 2024⁴. From 2022 to 2025, Spring’s internal data shows a 131% increase in frequency. Total claim dollars exceeding $1 million have increased by over 200% from 2023 to 2025.

At the highest threshold of $2 million, TMHCC reported frequency increases of 105% from 2021 to 2024, 65% from 2022 to 2024, and 22% from 2023 to 2024². Internal data shows a 59% frequency increase from 2024 to 2025 and a 162% increase from 2022 to 2025. Total claim dollars on claims over $2M have increased 96% from 2024 to 2025.

Impact of Pharmacy Claims

Pharmacy claims have steadily increased as a percentage of total claims over the past several years, both for underlying medical claims and stop-loss claims. Across one client block, we have seen pharmacy’s share of claims for stop-loss claimants more than double from 2019 to 2025 (from under 15% of claims to 30%). This underscores the growing role of pharmacy costs not only in aggregate claim spend, but specifically among high-cost stop-loss claimants.

Carrier Loss Ratio Deterioration

The surge in claims has materially impacted carrier profitability. Many major carriers reported higher loss ratios in 2024 compared to 2023, including industry leaders such as Cigna and United^5,6. Cigna explicitly identified stop-loss as the primary driver of its increased loss ratio, highlighting the outsized impact of this line of business⁶.

Market Hardening and Premium Increases

The combination of rising claims and deteriorating loss ratios has prompted a fundamental shift in carrier behavior. Double-digit premium increases have become commonplace and are directly attributable to the underlying claim trends. However, the current premium environment reflects more than actuarial updates to projected claims.

The market has entered a hardening phase as carriers shift their strategic focus from growth to profitability. This shift has reduced the competitive pressure that previously constrained premium increases. Carriers are demonstrating less willingness to aggressively price for new business, recognizing that underpricing in the current environment poses unacceptable financial risk.

In their 2025 survey, Aegis reported stop-loss premium increases of 9% to 11%, with long-term premium growth expected to range from 10% to 12%⁸. These figures likely understate future increases, as 2025 rates were developed using partial 2024 claims data. Continued deterioration in claim experience through 2025 is expected to drive further premium escalation in 2026 and 2027.

This dynamic has created a compounding effect on premiums. Rates are first increasing to reflect higher projected claims and then receiving additional upward pressure as carriers apply less aggressive pricing relative to those projections. The result is a premium environment shaped by both actuarial realities and a strategic recalibration of carrier risk appetite.

The Role of Captive Insurance Companies

Captive insurance companies help employers manage total cost of risk by retaining a portion of medical stop-loss risk in house, allowing organizations to capture risk margin that would otherwise go to the commercial carriers. This becomes increasingly valuable in a hardening market, where carriers embed greater margin into premium rates.

QBE reports increased interest in medical stop-loss captives and notes that captives have delivered great value to employers⁴. Stealth estimates that captives now represent 10% of the MSL market⁷. Across our own book of business, we have observed many clients achieve strong results through stop-loss captive structures.
Outlook

The convergence of accelerating claim frequency, rising severity, and market hardening suggests that the current premium environment is likely to persist in the near term. Absent a reversal in underlying healthcare cost trends or the introduction of effective cost-containment measures, employers and plan sponsors should expect continued upward pressure on stop-loss premiums.

The market appears to be in a transitional phase, with carriers recalibrating pricing models to reflect a new reality of elevated claim costs and reduced tolerance for underpricing risk.

¹Voya. Stop Loss Paid Claims Analysis 2025. Available at: https://www.voya.com/voya-insights/stop-loss-paid-claims-analysis-2025
²TMHCC. 2025 Annual Report. Available at: https://www.tmhcc.com/en-us/-/media/project/tokio-marine/tmhcc-us/documents/2025-annual-report.pdf
³Sun Life. Medical Stop Loss Market Report. Available at: https://sunlife.showpad.com/share/O4RCCHRh9ke9xod6BdbOz
⁴QBE. 2025 Accident & Health Market Report. Available at: https://www.qbe.com/media/qbe/north-america/usa/files/accident-health/2025-ah-market-report.pdf
⁵Becker’s Payer Issues. Payers Ranked by 2024 Medical Loss Ratios. Available at: https://www.beckerspayer.com/payer/payers-ranked-by-2024-medical-loss-ratios/
⁶The Cigna Group. Fourth Quarter and Full Year 2024 Results. Available at: https://newsroom.thecignagroup.com/2025-01-30-The-Cigna-Group-Reports-Fourth-Quarter-and-Full-Year-2024-Results,-Establishes-2025-Outlook-and-Increases-Dividend
⁷Stealth Partner Group (Amwins). State of the Market 2025. Available at: https://www.amwins.com/docs/default-source/external-linked-documents/stealth-docs/stealth_sotm_2025.pdf
⁸Aegis. 2025 Medical Stop-Loss Premium Survey. Available at: https://www.aegisrisk.com/stop-loss-premium-survey

Overview

Leave planning is becoming a central component of absence management strategy. As workforce expectations evolve and leave programs grow more complex, employers are placing greater emphasis on tools that improve clarity, coordination, and overall employee experience.

At the same time, the market for “leave planning tools” is expanding rapidly. Carriers, third-party administrators (TPAs), and technology vendors are introducing new solutions, often using similar terminology to describe very different capabilities. This lack of consistency makes it difficult for employers to evaluate options and determine what is appropriate for their organization.

A structured, objective perspective can help employers navigate the evolving leave planning landscape, from understanding key concepts and market trends to evaluating integration, governance, and organizational readiness.¹

Defining Leave Planning

Leave planning has historically been managed through a combination of policy documents, HR guidance, and manual coordination. Employees were often responsible for navigating multiple sources of information, while employers managed compliance and administration behind the scenes.

Today, expectations have shifted. Leave planning is increasingly understood as a structured process supported by technology, designed to provide employees with clear guidance and to improve coordination across stakeholders.

There is no single definition of leave planning. For some organizations, it may involve providing centralized access to information. For others, it includes personalized guidance, workflow coordination, or integration with broader HR systems.

Importantly, the effectiveness of a leave planning solution is not determined solely by its level of sophistication. Employers must assess how well a tool aligns with their existing processes, systems, and organizational priorities. This requires a clear understanding of the problem being solved and the outcomes the organization is trying to achieve.

Market Trends Driving Adoption

Several factors are contributing to increased interest in leave planning tools.

• Employee Expectations: Employees expect clear, timely, and accessible information when planning for leave. An unclear experience can lead to confusion and dissatisfaction.
• Program Complexity: The growth of state-specific leave requirements, combined with employer-sponsored benefits, has increased the complexity of absence management. Coordinating these programs manually is increasingly difficult.
• Technology Advancement: Digital platforms and improved user experience design have enabled more advanced tools. However, capabilities vary significantly across vendors.
• Increased Demand with Practical Constraints: Employers increasingly view gaps in leave planning capabilities as a limitation. However, implementation may be constrained by cost, integration complexity, and limited internal capacity or technical skill sets. As a result, selecting the right solution is often a strategic and operational decision, not just a technical one.

The Expanding Role of AI in Leave Planning

Artificial intelligence is beginning to influence the development of leave planning tools. Some solutions incorporate AI to provide personalized guidance, generate timelines, or recommend next steps based on employee-specific inputs. These capabilities can improve efficiency and enhance the employee experience. However, they also introduce new considerations, specifically when automated outputs begin to influence decisions or actions related to employment.

Employers should evaluate how these tools function, what data they rely on, and how outputs are generated. The value of AI depends on how well it aligns with business objectives and how effectively it is governed within the organization. Regulators increasingly expect automated HR tools to be transparent, fair, and accountable.²

Emerging Risks and Compliance Considerations

As leave planning tools evolve, particularly those incorporating automation or AI, employers must consider a broader set of risks.

Bias and Disparate Impact

The U.S. Equal Employment Opportunity Commission has highlighted that automated tools used in employment-related contexts may introduce the risk of unintended bias and disparate impact, even when used for advisory purposes.²

Jurisdictional Requirements

Certain jurisdictions have introduced regulations related to automated employment decision tools. For example, New York City Local Law 144 requires bias audits and transparency for covered automated employment decision tools.² While not all leave planning tools fall directly within these requirements, the regulatory environment continues to evolve.

Governance Frameworks

Organizations may benefit from structured approaches to managing risk. The National Institute of Standards and Technology provides guidance through its AI Risk Management Framework, which outlines governance, mapping, measurement, and management practices.³

Employers should ensure appropriate governance structures are in place to support responsible use, transparency, and oversight.

Understanding the Capability Spectrum

Leave planning tools vary widely in functionality. A structured view of capabilities helps employers evaluate fit more effectively.

• Informational Guidance: Provides access to policies, eligibility criteria, and general timelines.
• Personalized Planning: Delivers tailored guidance based on employee inputs such as timelines and benefit estimates.
• Collaborative Planning: Enables coordination between employees, HR, and managers through shared workflows.
• Integrated Operational Planning: Connects with HR systems, payroll, and case management platforms to enable automated workflows and end-to-end process execution.

Understanding where a solution falls within this spectrum is essential for setting expectations and evaluating fit.

Considerations by Employer Size

The appropriate level of leave planning capability varies based on organizational size and complexity.

• Small Employers: Often prioritize simplicity and ease of implementation. Foundational tools may be sufficient when supported by external partners.
• Mid-Market Employers: Typically require structured solutions that improve coordination while remaining operationally manageable.
• Large and Jumbo Employers: Often require integrated solutions that scale across local and multi‑state regulatory jurisdictions and diverse employee populations, with emphasis on automation, governance, and system connectivity necessary to support compliance.

Alignment between solution capabilities and organizational needs is critical across all segments.

Key Questions for Employers

Before selecting or implementing a leave planning tool, employers should evaluate:

Business Needs

What problem is the organization trying to solve?
How will this improve employee experience or operational efficiency?

Integration and Fit

How will the solution connect with existing systems and workflows?
What operational changes will be required?

Data, Privacy, and Governance

What data is required and how is it managed?
What governance structures are needed to oversee usage?

Partner Alignment

What capabilities do current partners offer today?
How are those capabilities expected to evolve?

Organizational Readiness

Does the organization have the resources to support implementation?
Are employees and managers prepared to adopt the tool?

These considerations help ensure decisions are grounded in organizational priorities rather than market positioning.

The LEAVE Framework

To support structured evaluation, employers may apply the LEAVE framework:

L – Lifecycle Fit

Alignment with the full leave lifecycle from planning through return to work.

E – Experience and Equity

Consistency of the employee experience and consideration of equitable outcomes.

A – Architecture and Data

Integration with existing systems and management of data.

V – Vendor and Verification

Vendor maturity and the presence of validation or audit processes.

E – Ethics, Compliance, and Enablement

Alignment with regulatory expectations and the organization’s ability to govern and support the tool.

This framework provides a consistent approach for evaluating capability, risk, and organizational fit.

• Organizational Readiness: Successful implementation depends on more than selecting the right tool.
• Operational Readiness: Alignment with workflows and internal processes.
• Technical Readiness: Feasibility of integration with existing systems.
• Governance Readiness: Establishment of oversight structures to manage risk and compliance.
• Workforce Enablement: Clear communication, training, and change management for employees and managers.

Organizations that address readiness early are better positioned to achieve sustainable outcomes.

Conclusion

Leave planning tools are reshaping how organizations manage absence and support employees. While the market continues to evolve, variability in definitions, capabilities, and governance expectations will remain a central challenge.

Employers that take a structured approach grounded in clear objectives, disciplined evaluation, and organizational readiness will be better equipped to select solutions that deliver meaningful operational and employee experience value.

¹U.S. Equal Employment Opportunity Commission. Guidance on artificial intelligence and algorithmic fairness in employment-related decision-making, emphasizing employer responsibility under civil rights laws.
²New York City Local Law 144. Requires bias audits, transparency, and notice for covered automated employment decision tools used in employment contexts.
³National Institute of Standards and Technology. AI Risk Management Framework (AI RMF 1.0), providing governance and risk management guidance for AI systems.

In a recent article published by Captive Intelligence, our SVP, Prabal Lakhanpal, and Senior Consulting Actuary, Nick Frongillo, explain how severe claim frequency and severity in Medical Stop Loss is impacting employers and strategies to respond to deteriorating loss ratios and mounting claim costs. You can find the full article here.

Executive Summary

Absence management programs are under increasing pressure from regulatory expansion, workforce complexity, and heightened employee expectations. Traditional operating models, reliant on manual case handling and fragmented systems,are no longer sufficient at scale. Artificial intelligence (AI) is emerging as a practical enabler, not as a replacement for human expertise, but as a mechanism to improve consistency, efficiency, compliance, and the overall employee experience.  This is being accomplished through both operational execution and technology development, and points toward a more streamlined ecosystem in the near and longer-term future.

The Operational Impact of AI in Absence Management

Shifting from reactive case handling to guided employee journeys

Operational friction in absence programs is highly predictable. Intake errors, incomplete documentation, repetitive employee inquiries, and complex policy interactions account for a significant share of administrative burden. AI-powered conversational tools are increasingly deployed to manage these high-volume, low-variability interactions.

Rather than replacing case managers, however, AI can enable guided leave journeys —helping employees initiate requests, understand requirements, and receive timely updates without needing repeated human intervention. It can also improve clarity and consistency while reducing call volume and manual effort.

Reducing cycle times through targeted automation

Absence operations involve extensive repetitive work: generating notices, tracking deadlines, verifying completeness, and summarizing case histories. AI-driven automation can support these tasks by drafting correspondence, flagging missing information, and consolidating timelines for faster review.

Organizations such as the International Foundation of Employee Benefit Plans (IFEBP) emphasize that AI adoption in leave management is increasingly focused on speed, accuracy, and employee understanding, not simply cost reduction. Many vendors are therefore responding by embedding AI directly into absence workflows rather than positioning it as a standalone tool. The operational result is improved throughput, fewer reopenings, and more predictable outcomes.

Enabling proactive workforce planning

Historically, absence management has been reactive: organizations respond after a leave occurs. AI can enable predictive insights, including forecasting absence likelihood and duration to support staffing and coverage planning. Machine learning models can identify absence patterns and duration risk, while also emphasizing the need for validation, explainability, and ethical safeguards.  When used appropriately, these insights support planning and early intervention, and improved workforce scheduling and roster stability.

Strengthening compliance and risk controls

Absence and disability programs have inherent compliance risk, and can be subject to inconsistent decision-making, and financial leakage. AI techniques long used in insurance, such as anomaly detection and predictive flagging, can be applied to help focus investigative and quality assurance resources. Crucially, these tools are designed to surface risk signals, not replace human judgment. Oversight will remain essential, particularly in medically and legally sensitive cases.

Technology Development Trends Shaping the Future

Natural language as the primary interface

Absence management is policy-intensive and emotionally complex, making it well suited for natural language systems. Modern platforms are building AI capable of interpreting employee questions, retrieving relevant policy language, and providing clear explanations—while escalating uncertainty to human specialists.  While trust is foundational, effective systems are able to prioritize:

• Policy-source transparency
• Clear escalation paths
• Guardrails that prevent overreach
• Empathetic, employee-appropriate language

Intelligent document processing

Medical certifications and eligibility documentation remain unavoidable. Next-generation platforms are moving beyond digitization to document intelligence—extracting structured data, identifying missing elements, and summarizing key information automatically. This can reduce reviewer fatigue and improve consistency across cases.

Predictive analytics with governance

Predictive absence models are transitioning from experimentation to production. However, research in absenteeism prediction underscores the importance of bias testing, explainability, and appropriate use boundaries. Leading organizations are therefore pairing predictive analytics with governance frameworks that define acceptable use cases, monitor outcomes, and ensure privacy-by-design principles.

What Organizations Can Expect

In the near term, or over the next one to three years, the absence industry can expect to see a number of enhancements in the way that insurance carrier and third-party administrator (TPA) service models are operating as a result of AI utilization, such as:

• AI copilots supporting case managers with summaries, next-step guidance, and draft communications
• Employee-facing AI assistants embedded into delivery models
• Expanded use of predictive analytics for staffing and capacity planning
• More sophisticated fraud and leakage detection adapted from insurance analytics

In the longer term, the most significant shift is anticipated to be architectural. Absence, disability, payroll, and HRIS systems will increasingly operate as better orchestrated ecosystems, with AI coordinating workflows across platforms. Additionally, organizations can expect continuous compliance models, where policy changes are proactively tested against real scenarios and documented automatically reflecting broader AI governance trends in what has become an increasingly regulated and ever-changing industry.

Conclusion

AI is not transforming absence management by eliminating human involvement. Instead, it is enabling human-centered, scalable operating models that can reduce administrative burden, surface risk earlier, and improve the employee experience without sacrificing compliance or judgment.