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# CHOICE in practice: 10 organizations and the takeaways behind them
- URL: https://www.thefringetheory.com/ichra-choice-employer-examples/
- Published: 2026-10-30T17:51:56.000Z
- Updated: 2026-10-30T17:51:56.000Z
- Description: Who are the employers embracing CHOICE with open arms? Here are 10 examples.
- Author: Derek Winn
- Tags: Theory

Part 3 of the CHOICE series. Part 1: [In case of emergency, break glass](https://www.thefringetheory.com/ichra-choice-arrangement-employers/). Part 2: [It's good to have CHOICE(s)](https://www.thefringetheory.com/ichra-choice-side-effects-employers/).

If you have read the first two parts of this series, you have heard me make the case for CHOICE, formerly ICHRA, mostly in the abstract. This one is about who actually did it, what I can glean from them, and who is doing it for the 2027 plan year.

From what I could find, the honest headline is that the list of household names is short. Data suggests at least 50 employers with 1,000 or more employees offered an ICHRA in 2026, though that count covers only about half of the administrators in the market \[1\]. The employers that have moved are mostly mid-sized, and they come from workforces that could hardly look more different from one another: hourly restaurant crews, a county government, two hospitals, and the insurers that sell the coverage. Different workforces, same exit.

Most benefits leaders already know CHOICE exists and that it is growing. What this adds is a roster of named employers, what each one actually disclosed, why two very different workforces ended up in the same place, and where it has gone sideways. It is built from employer releases, administrator case studies, trade reporting and BLS data.

- What is your participation rate, enrolled over eligible, and what is it doing to your renewal?
- How old is the group you are actually rating, compared with the group you employ?
- If your workforce is nothing like a restaurant's, does any of this apply to you? (read on for the hospitals)

## The roster

**Centene (expanding).** Moved more than 700 Indiana-based employees to ICHRA in 2026 \[2\], and is extending CHOICE to its Ohio and Oklahoma employees for plan year 2027 \[3\]. The headcount for the two new states was not disclosed. Centene said the reaction in Indiana was more positive than it expected, particularly among younger workers, though people had plenty of questions about networks, formularies and funding \[2\].

**Oscar Health (adopting).** Moving its Florida-based employees off its group medical plans and onto CHOICE for 2027, which the company described as a first step toward more of its workforce \[4\]. Florida headcount was not disclosed.

**Jersey Mike's and Smoothie King.** Both were named as customers of Thatch, an ICHRA administrator, when it announced its Series C in September 2026 \[5\]. Dave's Hot Chicken was named as a Thatch client in 2025 \[6\]. None of the three has said how many employees are covered, or whether it is the corporate office, company stores or franchisees.

**Palisades Hospitality Group.** A California hospitality operator with more than 1,200 employees, over 500 of them eligible. It offered a PPO everywhere and a cheaper HMO in California. Going into 2024 the PPO's carrier quoted a 63% increase, on top of 25% the year before. In California only 30 of more than 400 eligible employees had picked the PPO, and outside California just 20 to 30 employees enrolled at all \[7\]. Palisades moved to ICHRA and kept its California group plan running alongside it \[7\]. The case study doesn't say how the two were split between employees, which is exactly the class question to put to your advisor. Its benefits manager put the size problem plainly: 500 eligible employees is "not a big organization in the world of insurance" \[7\].

**The Rose Group.** A 54-unit Applebee's franchisee with more than 3,000 employees \[8\], which also shows up in ICHRA case material with turnover and satisfaction figures attached. I could not trace those figures to a primary source, so I am not repeating them here.

**Monongalia County, West Virginia (year two).** The first local government to switch, moving 265 county employees in 2026 \[9\]. For 2027 the commission approved about $7 million for employee ICHRA accounts, roughly $1 million more than last year. Only 20 of the 265 employees will see increases of around $212 a month \[10\].

**Hancock Health, Indiana.** The system where CMS announced the CHOICE name. Hancock replaced a self-funded plan it had run for more than 20 years, after a 2025 survey found nearly 95% of associates unhappy with some part of their medical benefits. About 70% of eligible associates enrolled, choosing roughly 100 plans from five carriers. For its first year, Hancock projects an 18% cut in medical benefit costs, about $2.2 million, and a 63% cut in associate premium costs, about $1.5 million. It also expects 43% of associates to pay less than $10 a month \[11\]. Its administrator puts participation at 700 or more employees \[12\].

**Rush Memorial Hospital, Indiana.** A 25-bed critical access hospital that moved its entire workforce in late 2024, offering the ICHRA to all 370 employees from entry-level staff to the C-suite and the board \[13\]. About 220 employees and their dependents have enrolled. Employees can choose from six insurers across three states, and about 60% picked an Ambetter plan. The hospital reports a 45% cut in healthcare spend, just under $2 million a year, and is heading into its third year on the model \[13\]. Its HR head describes the arrangement as a recruiting and retention tool, and says some employees are now bringing spouses who have other employer coverage onto the plan, which under the old group plan would have been a risk \[13\].

## What the record shows, and what it does not

Overall, the evidence falls into three buckets.

- **Cost.** This is the strongest. Hancock projects $2.2 million off its medical benefit costs in year one, and another $1.5 million off what associates pay \[11\]. Rush reports a 45% cut, just under $2 million a year \[13\]. Monongalia County's commission president put the cost of staying on the old group plan at $9.3 million, against the roughly $7 million approved for allowances in 2027 \[10\].
- **Enrollment.** Hancock enrolled about 70% of eligible associates \[11\]. Rush reports about 220 employees and their dependents enrolled, out of 370 employees offered, so its rate doesn't read cleanly \[13\]. Compare both with the PPO Palisades replaced, which 30 of more than 400 eligible California employees had chosen \[7\].
- **Retention.** This is the weakest. Rush calls its arrangement a recruiting and retention tool \[13\], but none of these employers has published a before-and-after turnover number I could trace to a primary source.

In other words, the savings and enrollment numbers are on the record, though they are the employers' own figures and Hancock's are still projections. The retention case is thinner still, mostly what employers say rather than what they have measured.

## Why it holds for a restaurant

Let's break this down. The problem for a franchise operator is four fold.

- **Participation.** A group plan is priced on whoever enrolls. Young, healthy hourly staff often waive, and the people who stay are the ones who expect to use it.
- **Churn.** Accommodation and food services ran a total separations rate of 4.9% in August 2026, against 3.5% for all private industry and 3.0% for health care and social assistance \[14\]. That is a monthly rate. Every one of those separations is an eligibility event someone in a small home office has to track.
- **Age.** Individual coverage is rated per member, and a 64-year-old can be charged no more than three times a 21-year-old \[15\]. A young workforce buys at the bottom of that curve instead of paying its share of a group rate built around whoever enrolled. That, along with the allowance, is why Palisades said many younger employees pay nothing out of pocket \[7\].
- **Claims.** Palisades is the clearest case. The few employees who chose its PPO included some whose families had health issues needing specialized care, and its administrator ties the 63% quote to the high usage that followed \[7\]. In a group that small, my read is that a handful of large claims can be enough to push a renewal past 50%.

CHOICE has no participation minimum, the worker keeps the policy when they leave even though the allowance stops, and the employer's number is set in advance. For a workforce that turns over constantly, each of those is worth something on its own. Lastly, individual plans can't be priced on anyone's health status, so a group rated on its own claims stops carrying them into the next renewal.

## Why it holds for a hospital, which is the harder test

A hospital is close to the opposite workforce. More clinicians, higher wages, more families, an older average age, and staff who generally want their own hospital in network. If the individual market in their county is thin, these are the people who notice first. Physicians would be the hardest test of all, and I come back to them at the end.

Given that, the hospitals may be the more useful evidence of the two. Rush runs in a community of about 6,000 people and still put six carriers in front of its staff \[13\]. Hancock's associates spread across five carriers and about 100 plans \[11\]. The age problem is handled inside the design, since allowances can vary within a class by family size, and by age at up to the same 3 to 1 ratio \[15\]. In other words, the employer can fund the older nurse more than the younger one without carving anyone out.

Different workforces, same exit. The trigger was not the same, Palisades was staring at a renewal it could not absorb while Hancock's own people were unhappy with a plan it had run for 20 years, but in both cases the employer stopped carrying the risk of a small pool and let the individual market carry it instead.

## Where it goes sideways

None of this makes the exit free. I could not find a named employer that tried CHOICE and went back to a group plan, but I did find two whose switch came with real costs.

Janek Performance Group, a sales training company, lost its group plan when the carrier declined to renew, and the broker's replacement plan was projected at about 40% more. On ICHRA its costs still rose about 15%, with the company covering 80% of plan cost. Its HR director described "a lot of emotion" among key employees, and some staff had never heard of the marketplace \[17\]. BrightView Health, an outpatient addiction treatment provider in five states, moved off a self-funded plan in 2025 and found the benefits workload grew enough that it added a coordinator just to field employee plan questions \[17\].

Beyond those two, the gotchas are four fold.

- **Subsidy loss.** What does your allowance do to an employee's marketplace premium tax credit? The ACA affordability test sits right in the middle of that answer \[9\], and for a lower-paid worker an allowance may be worth less than the credit it displaces, which can leave them worse off than with no offer at all. KFF's Matthew McGough has pointed to lower-income workers and those with chronic conditions as the most likely to come out behind \[18\].
- **Networks.** Individual plans often carry narrower networks than group plans \[18\]. Someone mid-treatment, pregnant, or seeing a pediatric specialist is the most exposed, and so far nobody has published data that tracks how often a switch actually disrupts care \[19\].
- **The market moves under you.** Insurers proposed a median increase of about 15% for 2027 \[20\], and Cigna is leaving the individual market for 2027, which affects about 369,000 people \[21\]. A Robert Wood Johnson Foundation policy officer told HR Brew that ICHRAs don't really guarantee the predictability they are marketed on \[17\]. The employer's contribution is predictable, though what that contribution buys in a given county may change from one year to the next.
- **Geography.** Some counties simply have a thin individual market. Centene has said mostly rural states are a lower priority for its own expansion, partly because they may lack concentrations of employers \[22\].

Overall, the cost case is on the record, and so are the ways it can go sideways for the people on the other end of the allowance.

## The arithmetic

Three numbers to pull from your own file.

1. **Participation.** Enrolled employees divided by eligible employees. Palisades' PPO, chosen by 30 of more than 400 eligible California employees while the rest took the HMO, ran under 8% by my math \[7\], and many of the 30 were there because they expected to use it. The lower yours runs, the more likely your renewal is being priced on a self-selected slice of your workforce.
2. **The age gap.** Average age of enrolled employees against average age of all eligible employees. A wide gap in the older direction can point to the same thing as low participation, from another angle.
3. **The age curve.** Take the lowest cost plan in your rating area for a 21-year-old. Under the federal default curve a 40-year-old pays about 1.28 times that, and a 64-year-old three times it \[15\]. Run your eligible census through those factors and you will see roughly what each employee would pay for their own coverage before your contribution. Family coverage, tobacco use and the plan they actually pick will move those numbers, which is where your advisor comes in.

If participation is low and the age gap is wide, CHOICE is worth a closer look regardless of your industry. If participation is high and the group is young, a group plan may well be doing its job.

## What to do

- Pull the participation rate and the enrolled-versus-eligible age gap before your next renewal meeting, not during it.
- Ask your advisor for a county-level check of individual market carriers [where your people actually live](https://www.thefringetheory.com/ichra-choice-employer-tool/), including who is leaving for 2027\. Rush and Hancock worked because the choice was there.
- Ask your advisor to walk through affordability for your lowest-paid class first, since that is where the subsidy tradeoff bites.
- Budget for the support. Janek and BrightView both found the change took more hand holding than expected, so plan for enrollment help before open enrollment, not after.

**Bonus tip.** Talk with your consultant or advisor about what else can sit around the allowance to round out the offering. A comprehensive $0 virtual health program, a partnership with a local direct primary care clinic, or simply putting added or surplus dollars into the HRA for out-of-pocket costs can go a long way toward easing the shift to a decentralized plan. Each of these may carry its own compliance wrinkles when it sits beside a CHOICE arrangement, which is one more reason it is an advisor conversation rather than a checkbox.

## The Tail

What none of these sources confirm is whether the physicians went too. Rush says the whole workforce, from entry level to the board, and its administrator says clinicians to service staff \[13\]\[16\]. Neither names physicians, and many rural hospitals contract their doctors rather than employ them. Hancock does not say who was eligible at all \[11\]. A system that employs hundreds of physicians, with their families, their age profile and their expectations about networks, is a different test than a 370-person critical access hospital. Nobody has published that one yet.

## Sources

1. Take Command, ["The large employer shift: What 2026 data reveals about ICHRA adoption among ALEs"](https://www.takecommandhealth.com/blog/2026-data-ichra-adoption-ale?ref=thefringetheory.com), October 2026 (citing HRA Council 2026 data report, which covers about half the ICHRA platforms in the market). Administrator publication.
2. Becker's Payer Issues, ["Why Centene is moving some employees to ICHRA"](https://www.beckerspayer.com/?p=20124&ref=thefringetheory.com), 2025.
3. Centene Corporation, press release, ["Centene Corporation Demonstrates Commitment to CHOICE Arrangements through Benefit Programs in Indiana, Ohio and Oklahoma"](https://www.prnewswire.com/news-releases/centene-corporation-demonstrates-commitment-to-choice-arrangements-through-benefit-programs-in-indiana-ohio-and-oklahoma-302910801.html?ref=thefringetheory.com), October 16, 2026.
4. Becker's Payer Issues, ["Oscar employees in Florida to transition to CHOICE arrangements"](https://www.beckerspayer.com/workforce/oscar-employees-in-florida-to-transition-to-choice-arrangements/?ref=thefringetheory.com), September 2026.
5. Pipeline Road (reporting TechCrunch and Dealbreaker), ["Thatch raises $108M Series C at $1B valuation"](https://pipelineroad.com/news/20260916-thatch-raises-108m-series-c-at-1b-valuation-led-by-the-gener?ref=thefringetheory.com), September 16, 2026\. Secondary reporting; customer names are the company's own claim.
6. Pivot, ["Thatch: The startup putting health care choices back in employees' hands"](https://pivot.uz/thatch-the-startup-putting-health-care-choices-back-in-employees-hands/?ref=thefringetheory.com), 2025\. Secondary reporting.
7. Take Command, ["How Palisades Hospitality switched to ICHRA and avoided a 63% group plan renewal"](https://www.takecommandhealth.com/success-stories/palisades-hospitality?ref=thefringetheory.com), February 4, 2026\. Administrator publication.
8. The Rose Group, [company history](https://www.myrosegroup.com/company-history/?ref=thefringetheory.com), accessed October 2026.
9. healthinsurance.org, ["Individual coverage health reimbursement arrangement (ICHRA) / CHOICE Arrangement"](https://www.healthinsurance.org/glossary/individual-coverage-health-reimbursement-arrangement-ichra/?ref=thefringetheory.com), October 2026.
10. WAJR, ["Mon County Commission approves ICHRA Allowance Strategy for 2027 health insurance plan for employees"](https://wajr.com/2026/10/14/mon-county-commission-approves-ichra-allowance-strategy-for-2027-health-insurance-plan-for-employees/?ref=thefringetheory.com), October 14, 2026\. The $9.3 million figure is Commission President Tom Bloom's estimate of the cost of staying on the prior group plan.
11. Hancock Health, ["Hancock Health Hosts National Launch of Choice Arrangements"](https://www.hancockhealth.org/2026/09/hancock-health-hosts-national-launch-of-choice-arrangements/?ref=thefringetheory.com), September 2026.
12. Remodel Health, ["Case Study: Hancock Health"](https://remodelhealth.com/case-study/hancock-health?ref=thefringetheory.com), 2026\. Administrator publication.
13. Becker's Hospital Review, ["Indiana hospital credits expanded services to employee health insurance switch"](https://www.beckershospitalreview.com/finance/indiana-hospital-credits-expanded-services-to-employee-health-insurance-switch/?ref=thefringetheory.com), July 10, 2026.
14. U.S. Bureau of Labor Statistics, [Job Openings and Labor Turnover Survey, August 2026](https://www.bls.gov/news.release/jolts.htm?ref=thefringetheory.com), Table A, released September 29, 2026 (USDL-26-1547). Seasonally adjusted monthly total separations rates, preliminary.
15. 45 CFR 147.102 (age rating limited to 3:1 for adults); CMS, ["Final Guidance Regarding Age Curves and State Reporting"](https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/CMS/Final-Guidance-Regarding-Age-Curves-and-State-Reporting-12-16-16.pdf?ref=thefringetheory.com), December 16, 2016 (federal default curve for plan years from 2018: age 21 = 1.000, age 40 = 1.278, age 64 and older = 3.000); 26 CFR 54.9802-4 (ICHRA allowances may vary by age and family size within a class).
16. Pulse 2.0, [interview with Zorro CEO Guy Ezekiel](https://pulse2.com/zorro-profile-guy-ezekiel-interview/?ref=thefringetheory.com), 2026\. Administrator statement.
17. HR Brew, ["Some employers are putting health insurance in workers' hands. Here's how it's going"](https://www.hr-brew.com/stories/some-employers-are-putting-health-insurance-in-workers-hands-heres-how-its-going?ref=thefringetheory.com), May 29, 2026.
18. AJMC, ["ICHRA Growth Could Reshape Marketplace Risk Pools and Widen Access Disparities: Matthew McGough"](https://www.ajmc.com/view/ichra-growth-could-reshape-marketplace-risk-pools-and-widen-access-disparities-matthew-mcgough?ref=thefringetheory.com), 2026\. Interview with a KFF policy analyst.
19. Medical Daily, ["Workers Are Keeping Their Coverage but Losing Their Network as Employers Hand Over Cash Instead of Plans"](https://www.medicaldaily.com/ichra-employers-cash-instead-group-plans-network-continuity-477320?ref=thefringetheory.com), August 14, 2026\. Secondary reporting.
20. KFF, ["ACA Marketplace Insurers Are Proposing a Median Premium Increase of About 15% in 2027"](https://www.kff.org/quick-insights/aca-marketplace-insurers-are-proposing-a-median-premium-increase-of-about-15-in-2027/?ref=thefringetheory.com), August 4, 2026\. Proposed, not final, rates.
21. MedCity News, ["Could Cigna Exiting the Individual Market be an Indictment of ICHRA?"](https://medcitynews.com/2026/05/could-cigna-exiting-the-individual-market-be-an-indictment-of-ichra/?ref=thefringetheory.com), May 2026 (reporting Cigna's first quarter 2026 earnings call).
22. Becker's Payer Issues, ["Centene to launch CHOICE options in 4 more states"](https://www.beckerspayer.com/payer/choice/centene-to-launch-choice-options-in-4-more-states/?ref=thefringetheory.com), October 2026.

Fringe Theory is independent and unaffiliated. Views expressed are my own and do not represent those of my employer. Nothing here is legal, tax, medical, or investment advice. Figures described as modeled or derived are my own arithmetic from the public sources listed, not disclosed data.