Defensible health plan decisions

What “defensible” means

A health plan decision should be one the CFO and CEO 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 inside two services: the Renewal Snapshot first, then the Health Plan Cost Review only if the Snapshot says it is worth it. You touch two of them, the document handoff at the start and the decision at the end.

Renewal Snapshot: 5 business days, $0. Always first. Health Plan Cost Review: 2 to 3 weeks, $7,500 or $12,500 flat. Only if the Snapshot says it is worth it.

Stage 1: Intake

Paperwork comes first. Nothing paid, and nothing using your documents or claims, starts before 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: the Renewal Snapshot is $0. The Health Plan Cost Review is a flat fee set in your engagement letter: $7,500 for the standard scope, $12,500 when a self-funded structure is priced. The Snapshot names which applies before you pay anything. If coverage is placed through me, the carrier pays me a commission of $35 per employee per month. 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, audit rights.
• 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 your CFO 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. Same process from 10 up. 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.