How claims data can shape a smarter open enrollment strategy

Open enrollment planning usually looks forward: a new plan year, new rates, and new decisions. But some of the most useful insight is already sitting in your claims data. It shows how employees actually used their benefits over the past year, where costs concentrated, and where gaps in care may be forming. Read carefully, it can shape both your benefits strategy and the way you talk about it during enrollment.

How much you can see depends on how your plan is funded. Self-funded and level-funded plans typically get claims-level reporting straight from the carrier or third-party administrator (TPA). Fully insured employers don’t have that same access, but renewal exhibits, carrier utilization summaries, and broker benchmarking reports carry many of the same signals and support the same kind of analysis.

Here’s how to put that data to work, whether your plan year brought rising costs or steady performance.

Which claims trends actually matter?

Large individual claims grab attention because of their size, but they’re often isolated events that don’t say much about the health of your workforce overall. The patterns that carry more weight over time are the ones underneath: which conditions drive plan spending, how utilization is shifting, and where preventive care or chronic condition management needs more support.

When a plan has a tough claims year, there’s usually a story behind the numbers. Specialty pharmacy costs may have jumped because a few employees started high-cost therapies. Emergency room visits may have climbed while primary care visits fell, which points to an access or awareness gap rather than a sicker workforce. Before you decide how to respond, find out what’s actually driving the trend.

A good year deserves the same scrutiny, just with different questions. Low utilization can mean a genuinely healthy workforce. It can also mean employees are putting off care they need because of cost-sharing, confusion about what’s covered, or another barrier. If you had a strong year, look at your preventive screening rates. If those are flat while claims stay low, it’s worth confirming the full picture matches what you’d expect.

Pharmacy is the trend line to watch most closely. Employers project a median health care cost increase of 9% in 2026, driven largely by rising use of specialty medications, according to the Business Group on Health. These shifts show up in claims data well before they show up in a renewal, so reviewing this information regularly buys you time to respond thoughtfully instead of reactively.

How claims insight shapes your benefits strategy

Claims data is only worth as much as what you do with it. Once you understand the trends, the next question is whether your current benefits and programs still fit what your workforce needs.

After a difficult claims year, resist the instinct to scale back before you understand the driver. Rising claims tied to obesity or metabolic conditions might point toward expanded nutrition counseling or a carefully evaluated approach to covering GLP-1 medications. Growing behavioral health or substance use claims may be a signal to strengthen your employee assistance program (EAP) or widen access to counseling. A rise in cancer-related claims can build the case for care navigation or second-opinion programs, which tend to improve outcomes and help manage cost at the same time.

After a favorable year, shift the focus to reinforcing what’s working. Strong preventive care participation and well-managed chronic conditions are worth telling employees about. Consistent use of virtual care or EAP resources is a sign those programs are landing. A quiet year is a good time to keep investing in and promoting what’s already delivering.

Either way, claims trends rarely point to one clear answer. They’re a starting point for a bigger conversation about where to invest, what to promote, and what to adjust.

Make open enrollment an opportunity to educate

Open enrollment is one of the few moments each year when employees actually stop and think about their benefits. That makes it a good time to explain not just what’s offered, but why.

If you added a program to address rising specialty pharmacy costs or growing behavioral health needs, say so. Context helps employees see the value of a change instead of just bumping into it. And if you had a strong year, calling out the behaviors that contributed is a concrete way to show the plan’s value beyond the premium. Grounding your enrollment messaging in real data, rather than general benefits talk, helps employees connect their own choices to how the plan performs.

Why claims data belongs in your enrollment plan

Claims data is more than a renewal metric. It’s a year-round picture of how your people use and experience their benefits, and it points toward different priorities depending on how the year went. A plan under cost pressure benefits from a targeted response to what’s driving it. A plan that’s performing well benefits from continued investment in what’s already working. Either way, a strategy built on workforce data holds up better than one built on assumptions.

Frequently asked questions

What is claims data and why does it matter for open enrollment?

Claims data shows how employees used their health benefits over the plan year, including which conditions drove spending, how utilization shifted, and where care gaps exist. It matters for open enrollment because it tells you what your workforce actually needs, rather than what you assume they need.

Can fully insured employers see claims data?

Not at the claims level, in most cases. But renewal exhibits, carrier utilization summaries, and broker benchmarking reports provide many of the same signals and support the same analysis.

What should employers look for in a good claims year?

Check preventive screening rates. Low claims paired with flat screening rates can mean employees are delaying care rather than staying healthy.

How early should employers review claims data before renewal?

Review it regularly throughout the year. Cost trends, especially specialty pharmacy, appear in claims data months before they appear in a renewal.

The Bright Side

Claims data can look like a pile of numbers, but it’s really just your people telling you what they need. The employers who get the most out of it aren’t the ones with the most sophisticated reporting. They’re the ones who look early, ask why before they ask what to cut, and let what they find shape the conversation they have with employees at enrollment. Daybright helps employers turn that insight into a plan that holds up, through one partner for Employee Benefits, Retirement, Compliance, and Individual Financial Planning. Want help reading your claims data before renewal? Contact us at daybright.com/contact.

Source: Adapted from Zywave content.

This post is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers should contact legal counsel for legal advice. Content sourced from Zywave.

• Category: News
• Tag: Employee Benefits