Exemplar Health Benefits Administrator

What Exemplar Health Benefits Administrator does

Exemplar Health Benefits Administrator (EHBA) is a private third-party administrator (TPA) headquartered in High Point, North Carolina, founded in 2018 and operating with 11-50 employees. The company administers self-funded and level-funded group health benefit plans — including claims adjudication, utilization and case management, pre-certification, member and provider services, COBRA administration, compliance management, network solutions (PPO and Reference-Based Pricing), reporting and analytics, pharmacy benefits, stop-loss facilitation, telemedicine, and balance bill negotiation — primarily for U.S. employers ranging from as few as five enrollees up to several hundred lives, licensed across 47 states.

The core commercial product is the Royalty Series, a level-funded platform packaging twelve pre-configured metallic health plan designs (Bronze through Platinum) with two network options — a First Health Network PPO and a PHCS-based Reference-Based Pricing model — plus a residual-claim refund structure (0%, 50%, or 100% of remaining claim fund returned to the employer at contract end). Underlying technology consists of proprietary claims processing systems integrated with industry-leading administration software, supported by an online reporting and analytics suite and four dedicated stakeholder portals (member, employer, provider, advisor), with eligibility and prior authorization handled through Medireview and urmedwatch.com integrations.

EHBA monetizes through third-party administration fees on managed self-funded and level-funded plans, professional services fees tied to stop-loss shopping and carrier negotiation, and managed-services economics from PBM partnerships. Distribution is anchored by a channel-partner model: Exemplar Insurance Associates operates as the firm's Field Marketing Organization, recruiting insurance advisors who use census-based quoting and simplified underwriting to sell EHBA plans, complemented by a direct employer sales capability. EHBA is embedded in the broader Exemplar Family of Companies alongside Exemplar Healthcare Partnership Organization and Exemplar Physicians Clinical Management Services, and operates without disclosed external institutional investment.

Name

Exemplar Health Benefits Administrator

Legal name

Exemplar Health Benefits Administrator

Website

https://exemplarhba.com

Company type

Private

Founded year

2019

Operating status

Operating

Headcount range

11–50 employees

Short description

Exemplar Health Benefits Administrator is a private, North Carolina-based third-party administrator of self-funded and level-funded group health benefit plans for U.S. employers of 5 to hundreds of lives, distributed through its Royalty Series product across 47 states via a dedicated insurance-advisor channel.

Ownership category

akta.pro rank

Product category

Third-Party Health Benefits Administration

NAICS

Pharmacy Benefit Management and Other Third Party Administration of Insurance and Pension Funds (524292), Health and Welfare Funds (525120), Insurance and Employee Benefit Funds (5251)

SIC

Hospital & Medical Service Plans (6324), Insurance Agents, Brokers & Service (6411), Services-Health Services (8000)

akta.pro primary industry

Level-Funded Group Health Plans (FSAIAFAC)

Keywords

• Third-party health benefits administration
• Self-funded health plans
• Level-funded group insurance
• Stop-loss insurance procurement
• Pharmacy benefits management

Headquarters

HQ city

High Point

HQ country

United States

HQ region

North America

Offices1 record

Markets served

GTM type

B2B

Offering type

Services

Cost components

Personnel, Technology or R&D, Operations, Marketing or Sales, Infrastructure

Revenue model

1. Third-Party Administration Fees: EHBA charges administrative fees for managing self-funded and level-funded health benefit plans. This includes claims administration, member services, utilization management, and other TPA services.
2. Stop-Loss Insurance: EHBA facilitates stop-loss coverage by maintaining relationships with major stop-loss carriers. They shop stop-loss insurance to ensure employers have optimal protection at affordable prices for their self-funded or level-funded plans.
3. Pharmacy Benefits Management: EHBA facilitates pharmacy benefits through partnerships with Pharmacy Benefit Managers (PBMs), delivering national accessibility with cost-effective prescription drug options and specialty drug programs.

Pricing tiers

Go-to-market motion2 records

Distribution channels4 records

Marketing channels3 records

Core offering

EHBA administers self-funded and level-funded group health benefit plans for employers, anchored by its Royalty Series product line of 12 pre-bundled metallic (Bronze through Platinum) plan options. The company provides a full suite of third-party administration services including claims adjudication, member and provider services, utilization management, case management, pre-certification, COBRA administration, compliance management, pharmacy benefits management, stop-loss insurance procurement, network solutions (including Reference Based Pricing), reporting and analytics, telemedicine, and balance bill negotiating. Plans are available for employer groups as small as 5 enrollees up to hundreds of lives across 47 U.S. states.

Product overview

Exemplar Health Benefits Administrator (EHBA) is a third-party administrator (TPA) specializing in the group insurance market, administering self-funded and level-funded health plans. The company's product portfolio is organized around its core Royalty Series platform (offering 12 metallic health plan options for employers) supported by a comprehensive suite of administrative services including Claims Administration, Member Services, Provider Services, Utilization Management, Case Management, Pre-Certification, Pharmacy Benefits, Stop-Loss Insurance, Telemedicine, COBRA Administration, Compliance Management, Network Solutions, Reporting and Analytics, and Balance Bill Negotiating. The company also provides multiple self-service portals (Gateway/Member Portal, HICard Portal, Employer Portal, Provider Portal, and Advisor Portal) enabling different stakeholders to access account information, eligibility checks, and plan management tools.

Differentiator

Problem solved

Functional benefit

Brands

• Royalty Series: Level-funded health plan product line with twelve metallic health plan offerings for employer groups.

Products and services

• Royalty Series Level-funded group health insurance product offering twelve metallic health plan options (Bronze through Platinum) for employers with 5 to 100+ employees across 47 states, featuring PPO and Reference Based Pricing network options, no employer contribution requirement, and 0%, 50%, or 100% of remaining claim fund returned to employer after contract period.
• Claims Administration Claims adjudication and processing through proprietary systems and industry-leading software to ensure compliant, timely, and accurate claims management for self-funded and level-funded plans.
• Member Services Customer service team assisting members through every step of their health plan, providing guidance and optimal solutions.
• Provider Services Services facilitating provider access to eligibility checks and claim status information through online portals.
• Telemedicine Virtual medical care options providing convenient, efficient, time-saving, and cost-effective solutions for primary care and urgent care visits.
• COBRA Administration Complex COBRA program administration including compliance, financials, and reporting on behalf of clients.
• Compliance Management Ensures all benefits are in compliance with applicable rules and regulations, maintaining plans within state and federal regulations.
• Network Solutions Access to large PPO networks (First Health Network, PHCS) and reference-based pricing model administration for doctors and facility access.
• Reporting and Analytics Robust advanced reporting and analytics tools with online access for self-funded and level-funded employers, providing insights into each plan and suggestions to support plan goals.
• Pharmacy Benefits PBM selection and management (including transparent pass-through PBM partnership) delivering national accessibility with convenient, cost-effective prescription drug options and specialty drug programs.
• Stop-Loss Insurance Stop-loss carrier relationships and shopping services providing optimal protection at the most affordable price for self-funded and level-funded plans, working with major stop-loss carriers.
• Pre-Certification Pre-certification requirements designed to ensure members receive the right care at the right time, with tailored and updated pre-certification lists.
• Utilization Management Review of medical necessity, appropriateness, and efficiency of healthcare services with nurse professionals and physician specialist support.
• Case Management Monitoring of all claims from physicians, hospitals, and healthcare providers to detect fraudulent billing and inflated costs, minimizing expenses.
• Balance Bill Negotiating Member advocate assistance for balance billing scenarios including procedure scheduling, financial term negotiation, and out-of-pocket cost limitation.

Segments3 records

Ideal customer profiles3 records

Technology focussed No

API detail

Has API

No

API docs

API detail

Core technology

AI maturity

App detail

Feature2 records

Partnerships

Five partnerships are on record, tiered core.

• Exemplar Healthcare Partnership OrganizationcoreStrategic or Co-development PartnerProud partner and part of the Exemplar Family of Companies. Described as the nation's largest independent healthcare network connecting members to trustworthy pharmacists and physicians.
• Exemplar Insurance AssociatescoreChannel Partner/ Reseller/ DistributorField Marketing Organization (FMO) for Exemplar Health and Insurance products. Manages distribution of Royalty Series products through a select network of advisors. CEO Tim Hawley leads the distribution efforts.
• First Health NetworkcoreTechnology or IntegrationPrimary PPO network option for EHBA's traditional plan offerings, providing access to discounted healthcare providers across the country.
• PHCS Practitioner NetworkcoreTechnology or IntegrationUsed in conjunction with Reference Based Pricing model for practitioner services. Part of EHBA's RBP solution that has revolutionized how healthcare is utilized and paid for.
• Major Stop-Loss CarrierscoreTechnology or IntegrationEHBA maintains strong relationships with some of the largest Stop-Loss carriers in the world to shop stop-loss insurance for the best protection at affordable prices for self-funded and level-funded plans.

Scale indicators3 records

Recent moves6 records

Expansion highlights5 records

Direct peers

• TASC (Total Administrative Services Corporation): TASC is a national third-party administrator of employee benefit plans including FSA, HSA, HRA, COBRA, and commuter benefits. It is directly comparable to EHBA as a TPA serving employer-sponsored group benefits across multiple states.
• Benefit Plan Administrators (BPA): BPA is a third-party administrator focused on self-funded health plans for mid-market employers, with level-funded product offerings, PPO access, and integrated stop-loss placement — closely mirroring EHBA's Royalty Series positioning.
• HealthScope Benefits: HealthScope Benefits is a TPA administering self-funded and level-funded group health plans for employers across multiple states, with PPO networks and stop-loss partnerships — a direct functional peer to EHBA's core offering.
• Auxiant: Auxiant is a TPA administering self-funded health plans for employers, with reference-based pricing, stop-loss, and integrated wellness offerings. Comparable to EHBA on product breadth and mid-market employer focus.
• Allied Benefit Systems: Allied is a TPA offering self-funded health plan administration, stop-loss, PPO networks, and integrated benefits technology for employer groups. It overlaps directly with EHBA's self-funded/level-funded administration and advisor-distributed model.
• Star Marketing & Administration Inc. Star Marketing is a managing general underwriter and TPA focused on level-funded and self-funded small-group health plans distributed through insurance advisors — a near-direct analogue to EHBA's Royalty Series model.
• Diversified Group: Diversified Group is a TPA providing self-funded medical, dental, vision, and worksite benefits administration to employers nationwide, with strong advisor channel relationships — overlapping heavily with EHBA's go-to-market.

Broad incumbents

• BenefitMall: BenefitMall is a larger, established benefits broker and technology platform distributing group health, payroll, and HR solutions through thousands of insurance advisors. Comparable as an incumbent channel-driven benefits distribution and administration competitor.
• Zelis: Zelis is a large healthcare technology and services company offering claims administration, network solutions, payment integrity, and TPA-adjacent capabilities to payers and employers. Comparable as a broader, well-capitalized incumbent operating across many of EHBA's service lines.
• Word & Brown General Agency: Word & Brown is a large national general agency distributing group health, dental, vision, and voluntary benefits through insurance brokers across multiple states — directly overlapping EHBA's advisor distribution motion.

Market position

Strengths5 records

Weaknesses5 records

Competitive moat5 records

Key risks5 records

Key highlights7 records

Customer concentration

Revenue estimate

Valuation estimate

Number of profiles

Funding overview

Funding rounds

Investors

Funding detail is available on the Subscription and Enterprise plan.Contact sales →

M&A

Investments

M&A and investment is available on the Subscription and Enterprise plan.Contact sales →

Frequently asked questions about Exemplar Health Benefits Administrator