Improve Your Health Plan One Question at a Time.

Most employers don’t realize they’re managing one of their largest spend categories with zero upstream visibility. Stop and let that settle in. Benchmarking and claim costs, your traditional measures of plan performance, are lagged, reactive, and downstream.

Enter the Plan Grader Lite. Built on questions not typically asked, this 11-question assessment is specifically designed to help you quickly see and evaluate your upstream metrics. From who you partner with to who ‘owns’ your data, these upstream questions lead to downstream results.

Question #1: Benefits Advisor

What: Does your benefits advisor completely disclose all direct AND indirect compensation on an annual basis?

Why: Who pays your benefits advisor? The answer is important. If part of their compensation is tied to a certain insurance carrier or solution, there are mis-aligned incentives. Are you getting independent, valuable advice?

Action Step: Have your advisor complete an annual fee disclosure; including direct AND indirect compensation. (Note: this should already be happening per the Consolidated Appropriations Act of 2021)

Question #2: Funding

What: What is your health plan’s funding arrangement? Self-insured, level-funded, or fully-insured?

Why: You and your employees are the payer of health insurance, period — no matter which funding arrangement you find yourself in. When possible, moving toward level-funded and self-insured arrangements to optimize choice and flexibility and lower costs.

Action Step: If fully-insured, explore level-funded. If level-funded, explore self-insured. If self-insured, optimize partners and programs. Each year is a new opportunity to evaluate the numbers.

Question #3: Contracts

What: Does your health plan utilize Employee Retirement Income Security Act (ERISA) counsel for document and contract review and negotiations (e.g., audit rights, capped fees, data rights)?

Why: If the contract hasn’t been reviewed or negotiated, it is not written in your favor. It’s time to take back some rights.

Action Step: Hire an ERISA subject matter expert to review contracts.

Question #4: Multi-Year Strategy

What: Do you have a 2-3 year benefits strategy?

Why: Your health plan is one of your business’s top two or three line items, so it deserves attention and strategic planning. Without a multi-year strategy, where are your benefits headed?

Action Step: Work toward creating a multi-year strategy.

Question #5: Data

What: Does your health plan have full, unrestricted access to detailed data (by procedure code, by provider, etc.)?

Why: Without access to YOUR data, how can you make informed decisions?

Action Step: Own your data and cite the CAA’s ‘Gag Clause.’ (See #3 above, as well.)

Question #6: Partner Flexibility

What: Does health plan have flexibility to select a pharmacy benefit manager (PBM) and stop-loss carrier?

Why: Without the freedom and flexibility to choose these partners, you as the buyer lose purchasing power: the ability to negotiate, drive competition, and create favorable outcomes for your health plan.

Action Step: Move to and work with partners that allow PBM and stop-loss flexibility.

Question #7: Communication

What: How often does your company communicate benefits information to employees? Once a year, once a quarter, once a month?

Why: Health insurance is so complex! Too complex! The more you communicate, the higher likelihood employees will learn and know about resources.

Action Step: Keep communicating. You never know when a message will resonate with an employee.

Question #8: Primary Care

What: Does your plan offer Virtual Primary Care (not just telehealth), On-site Clinic, Near-site Clinic, or Direct Primary Care (subscription based, same day, next day accessibility to primary care)?

Why: Value-based primary care (NOT fee for service) is the core to effective care and health.

Action Step: Explore Direct Primary Care (DPC).

Question #9: Transparent Network

What: Does your plan utilize any Direct Contracting, Bundled Care Arrangements, Reference-based Pricing (RBP), or alternative network solutions?

Why: An MRI can cost $500 or $3,000, all depending on where you go. Same image, very different price. Price transparency needs to be the standard, not the exception.

Action Step: Assess direct contracts and bundled payments in your market.

Question #10: Point Solutions

What: Do you offer unique resources and support for chronic conditions or specialty care (Cancer, Musculoskeletal, Diabetes, Maternity, etc.)?

Why: Innovation and technology have changed the game for patient care across many niche conditions. Your employees will thank you.

Action Step: Evaluate your company’s needs and explore point solutions to support your members.

Question #11: Pharmacy Benefits

What: Does your health plan use Optum, CVS, or Express Scripts (ESI) for your Rx benefits?

Why: Pharmacy benefits are among the lowest-hanging fruits to immediately impact your health plan.

Action Step: Go conduct an RFP for your pharmacy benefits and include multiple transparent pharmacy benefit managers.

Did you know? Plan Grader Lite was included in Study Groups’ Employee Compensation Survey (ECS) 2025. If you didn’t get a chance to complete the survey and receive your assessment, complete it now using the QR Code below.

Don’t wait to take action! Tackling even 1 of the 11 questions during this health plan renewal cycle will create momentum and reap rewards.

If you want to see what one small change could do to improve your grade, let’s talk.