By DEEKSHA HEGDE
How to spot a fundamental business model shift from a mile away, long before the PR calls it a product launch or market expansion.
In April 2026, Progyny, a fertility and family building benefits administrator, announced Progyny Select, a supplemental health plan for small and mid-size employers (100-1,000 employees). “Pooled-risk” got me curious: did they cut a deal with an insurance carrier to back the product, or had they taken on insurance risk themselves?
Until now, Progyny had only served large, self-insured employers (1,000+ employees) as a third-party administrator. They negotiated rates with fertility clinics, routed employees to better providers, managed the claims paperwork, and took a margin while employers paid the medical bills. This product launch appeared to be a downmarket expansion to capture a segment previously untapped, but the mechanics were not apparent.
I didn’t have to look very far. It was right there in the legal disclaimer at the bottom of the press release: “through subsidiaries of Progyny Inc. with state licensure to offer supplemental coverage.” Now this really got my attention. This is a digital health company turning into an insurer. You don’t see that happen every day. I decided to do some digging.
What states have they acquired licenses in, given you need one in every state you want to operate in? Their latest 10-K, surprisingly, didn’t mention anything about their flip to the insurer model. I realized they were not required to disclose the new insurance subsidiary since it hadn’t crossed revenue thresholds by the SEC’s definition. The fully insured expansion appeared as a growth target and a regulatory risk factor. They declared the move would subject them to additional laws applicable to health insurance that do not currently apply to them.
The product landing page did mention Progyny Health Insurance Company of Washington. So I pulled the thread. Washington state incorporation records showed the name had been reserved in August 2024. Six months later, in February 2025, the entity was formally incorporated. By July 2025, Progyny Health Insurance Company of Washington had been admitted as an active health insurer by the Washington Office of Insurance Commissioner. In the second half of 2025, they filed their first few products with the regulator, all still sitting in review on the SERFF database as of July 2026. The filings also make nationwide coverage ambition explicit. So this has been stewing since August 2024, the date the name was chosen. I went on LinkedIn to check if they had any actuaries on the team. They hired an actuary in April 2023, and a second in January 2026 (who specializes in pricing insurance products) three months before the launch.
The announcement that the press called a product launch had been a strategic transformation at least three years in the making. The SEC filings hinted at it. These four signals — an actuary hire, a name reservation, an insurance license, and active product filings with a state regulator — were sitting in plain sight the whole time. For anyone watching, just one of those foreshadowed what was coming.
I’ve been watching the market reaction since the launch. The move is still being read as market expansion downward, when it’s really business model innovation.
Why become an insurer at all?
For small fully insured employers, the health plan itself bears the claims risk, and no carrier wants to absorb a $15,000 IVF cycle in a pool of 100 people, so incumbents leave fertility out of the base plan. Self-insured employers are a finite market Progyny has been working for a decade. To reach the fully insured employer market, someone had to hold the risk. In my previous pieces on Function and Hinge, I argued that the companies that scale to win insurers over are the ones generating enough outcomes data to earn actuarial credibility. Progyny took that one step further. Instead of using their data to convince an insurer, they became one. And it makes total sense. They hold 10 years of proprietary fertility claims data. They know what claims cost, across which demographics, with what variance. Becoming the risk-bearing entity who can price it accurately opens them up to underwriter margins while they’ve been operating with TPA margins all this while.
Holding proprietary data that gets better with time is only one part of why they could afford to venture into underwriting. Here’s everything else that was true simultaneously:
- Coverage is for a discrete, priceable event. One IVF cycle costs between $12,000 and $20,000. Actuaries can model this.
- Small employer health plans typically don’t cover fertility, so there’s a gap to fill. This avoids the complexity of going up against an incumbent insurer.
- They’ve published independently validated outcomes: Milliman-audited live birth rates, cost per live birth, superior to national benchmarks. They can underwrite confidently.
- They control the drug costs with Progyny Rx, the in-house PBM. They can negotiate drug pricing at scale and steer members toward cost-effective protocols.
- The credibility with employers has already been built. They named it Progyny Select and not a new brand. Select sells through brokers, which is a new channel for Progyny, but with the brand and outcomes track record of a decade.
- They are a profitable public company that can afford the capital reserves that need to be locked up to satisfy the regulatory requirement. In WA, that is $4 million minimum.
There are several ways to price optimally, but given the PR said “pooled risk” and that they only have two actuaries, I figured the PEPM would not be bespoke. Small fully-insured employers are eating 10–13% premium increases on base medical YoY. I was curious whether Progyny can price low enough for a founder or Head of People to be convinced when a broker pitches “This is $xx PEPM you can advertise as a differentiated benefit, and it costs less than losing one employee to a competitor with fertility coverage.”
Declared in the regulatory filings are their plans for a single pool with a 2-tier PEPM based on whether the coverage is for just employee (and employee + children since it doesn’t matter) priced at $11.15, or employee + spouse (again, with or without children doesn’t matter) priced at $30.17. This proposal, which projected the loss ratio to be 77% (aka 23% goes to admin, taxes, profit), was “referred” for additional scrutiny. Shortly after, Progyny revised the loss ratio to be 102% and declared they expect this product to be a loss-leader that will eventually turn a profit. In the meantime, the public parent will bankroll the insurance subsidiary. The PEPM tiers did not change, but the whole filing is still under review.
But wait. Progyny isn’t just a fertility company anymore. Over the past three years they, like several others who used fertility as a wedge, have built out a full women’s health platform with pregnancy, postpartum, menopause, and parenting. Select includes all of it. Take menopause as an example, which is not a discrete event. It’s chronic, ongoing, highly variable care, and Progyny has at most three years of data on it. So how exactly are they underwriting this bundle? I went back to the launch messaging and features list. Fertility: “comprehensive coverage, including IVF, IUI, and genetic testing.” Pregnancy, postpartum, parenting, menopause: “coaching,” which is simply care navigation and coordination. These are all valuable to members and attractive to employers, but the insurance risk is scoped to fertility.
That’s key because there’s a cautionary tale from not too long ago. Babylon Health, an AI-based PCP triage company, tried to become a risk-bearing provider by acquiring ~50,000 capitated Medicare/Medicaid lives. They announced it loudly in 2021 as part of a $4.2B SPAC narrative: “the largest digital-first value-based care provider in the US.” They bolted a risk-bearing structure covering the most expensive population in American healthcare onto a tech company without clinical infrastructure and cost management capability. Two years later, they filed for Chapter 7 bankruptcy.
Back to Progyny. Alongside the fertility product, WA records show a second product filing around the same time that hasn’t made it into any press release or media coverage. A supplemental termination of pregnancy insurance intended to fill gaps for employers whose base carrier declines coverage due to religious objection. Whether this product has since been shelved, made available through the broker channel without public fanfare, or staged for a later announcement, I don’t know. What I do know is that they declared to offer this at near break-even (tier 1 at $0.12 and tier 2 at $0.32 PEPM), with a 96% loss ratio (remaining 4% revenue covers admin, taxes, profit). It appears to be a low-cost, strategic door-opener to the fully-insured market that sets up the relationship for their core fertility product.
Who else can pull off the underwriter model in the near future? Carrot, Progyny’s direct competitor that launched when Progyny was signing its first handful of employer clients, could be a fast follower. I didn’t find any full-time actuaries on their team, though. Maven Clinic started in the adjacent maternity space and added on fertility benefit management in 2024 as the whole market was pushing to own the full spectrum of women’s health. Maven and Progyny collided as they expanded outward, with both now competing head-to-head for self-funded employer budgets. Maven’s dataset is newer and thinner with likely several years before a Select-esque venture.
The data advantage that Maven does have is in what was their beachhead: maternity. High-risk pregnancies, when they end in preterm births and NICU stays, can cost from $75,000 to over a million in extreme cases. Even with stop-loss insurance, self-funded employers can blow through their budget in a bad year. Applying the framework from above, pregnancy complications constitute a discrete, high-cost tail event that base plans leave employers exposed to, in a small percentage of the population, for which Maven has years of data to price. Maven has a lane, but it’s harder than Progyny’s because the cost spread is wider. Put another way, Progyny is taking utilization risk on discrete, priceable events. Maven would be taking tail risk on rare, catastrophic events.
Maven’s core product can address this, though. Their maternity coaching would identify high-risk pregnancies early and route members to better care. This would serve as the cost management layer of the insurance product, while unlocking insurance margins (if done right) and market expansion. To tie the two products together, Maven could make coverage conditional on a minimum level of patient engagement with their clinical program.
If this hypothetical supplemental insurance is elective the way hospital indemnity is, families who are trying to conceive or already pregnant, especially those with known risk factors, self-select in and collapse the pool. For a pooled supplemental plan to work, enrollment needs to be employer-sponsored and universal, which is almost certainly how Progyny Select is structured.
Maven hasn’t shown their hand yet. When I started writing this piece in May 2026, I did find another digital health company with three actuaries on their team. Virta Health added two actuaries in December 2025 and February 2026. Virta was unique in offering their diabetes reversal program at risk against reduced HbA1c outcomes so they probably needed their early actuary for value-based care modeling. I wondered if Virta actuaries were simply scaling value-based care as the company was growing?
Coverage for metabolic care is established in base plans but no entity is accountable to keep spend low in the incentives game that healthcare is. GLP-1s for weight loss are projected to be a source of uncontrolled costs for employers. In June 2026, Virta announced GLP-1 access for employers with guarantees like 0% YoY utilization increase and 1:1 claims-based ROI. Is Virta stopping here, or is this the intermediate step to full capitation?
Either way, the signals precede the press releases, if you know where to watch.
Disclaimer: This is not investment advice. I hold no position in any company mentioned.
Deeksha Hegde is a bioengineer who writes about healthtech and digital health on her Substack, connecting dots beyond the press releases.
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