Defensible health plan decisions

What “defensible” means

A health plan decision should be one your company can defend: not just what was chosen, but how.

• It supports fiduciary duties. A prudent process, reasonable fees, and acting in participants’ interest.
• It supports disclosure requirements. Knowing what is paid, to whom, and why.

The five stages at a glance

The five stages run after you switch brokers: the Plan Report first, then the renewal strategy and market. You touch two of them, the document handoff at the start and the decision at the end.

Plan Report: written from the inside once I take over servicing. No quotes and no savings estimate yet. Always first. Renewal strategy and market: from about 90 days out, with the renewal in hand, firm quotes in 20 to 25 days. The market is shopped whether the renewal is high or in line.

Stage 1: Intake

Paperwork comes first. Nothing is analyzed or quoted, and none of your documents or claims are used, until the engagement letter and broker-of-record letter are signed. My pay is in writing, in dollars and per employee, before you sign.

What I request: your employee census, current plan summaries, the renewal, and any fee or compensation disclosures. Claims reports (24 months), pharmacy reports and the stop-loss contract help, but are not required on day one.

I confirm: the decision deadline, and who holds decision authority, so nothing stalls later.

What it costs: onboarding, servicing, the Plan Report and the renewal strategy are included. They are paid through the plan as placement commission, not billed to you. Until your first renewal with me, the carrier pays the commission already in the contract, shown in dollars before you sign. From that renewal, the commission is a flat $40 per employee per month at standard scope. Special projects, for example a self-funded structure, are priced in the engagement letter before you sign, never added later. All of it is disclosed in writing, in dollars and per employee, before anything is signed. How I’m paid.

Stage 2: Due diligence on plan spend

The renewal number alone says nothing. I take it apart.

• Renewal analysis. The increase split into its five drivers: trend, experience, demographics, plan design and fees.
• Medical cost review. High-cost claims, site-of-care patterns and price variation.
• Pharmacy cost review. Specialty share, generic use, and contract terms: spread, rebates, rights to inspect claims data.
• Fee review. Every party the plan pays, and on what basis.

Everything I find goes into a documented findings log.

Stage 3: Benchmarking

The output shows where your plan sits against its peer band on cost per employee, contribution split and deductible. I benchmark market pricing. When a fee reasonableness opinion is needed, it comes from an independent firm. See the Health Plan Visibility Studies for what the public filings alone can show.

Stage 4: Options and stress test

I market each path across carriers and administrators, then model cost, risk and employee impact.

Plan design and contribution scenarios run against each path. Where stop-loss is in play, the contract terms matter as much as the price: specific versus aggregate coverage, attachment points, lasering, renewal protections, and the cash you need on hand. More on the trade-offs: level funded vs fully insured.

Under 50 employees, ICHRA and QSEHRA are options too, with the trade-offs in writing.

Stage 5: Recommendation and the record

Two deliverables.

The owner-ready summary: the recommendation, the reasons for it, and the alternatives considered. Short enough to read in one sitting, and built so whoever owns the decision can present it directly.

The decision file: the sources and benchmarks used, the assumptions and risks noted, the fee and disclosure review, and a dated decision trail of who decided what. That file is what holds up later. See one built end to end in One plan, start to finish.

Who does what

Built for 50 to 500 employees. ACA large-employer rules start at 50 full-time equivalents, and part-time hours count, so groups near 50 should plan before they cross.

Advisory analysis, not legal or tax advice.