The strategy catalog

Fully insured (baseline)

{current_carrier}'s renewal comes in at {renewal_increase_pct} ({renewal_increase_dollars} a year). A fully insured contract is more than the fixed portion of a risk-bearing arrangement, but it is the whole cost — exposure stops there.

No gates — available to any client.

Moving TO fully insured RE-INSTATES state-mandated benefits and state continuation that self-funding pre-empted. ⚠️ The mirror of the level-funded interlock — the compliance checklist GROWS on this move, which is easy to miss.

Level funded

Level funding gives {employer} a fixed monthly cost like a premium, with a refund if claims run low. Expected total {expected_total} against a fully insured {fully_insured_premium}. A bad year uses up the cushion rather than costing more. How it gets underwritten matters at this size: {underwriting_summary}

• Eligibility Funding fully insured
• Market Level funded carrier exists

• incompatible self-funded-stop-loss
  Both are funding structures; a group has one.
• incompatible rating-methodology
  Leaving fully insured removes the rating-methodology lever entirely.

🔴 The plan becomes self-funded, so STATE CONTINUATION no longer applies (gated on funding === 'Fully-insured'), the ComplyDIY checklist changes, and the OE notice list changes with it. Say this at recommendation time.

• Texas stop-loss regulation and minimum attachment points (T2-1) — gates this at the small end.

Self-funded with stop-loss

Self-funding means {employer} pays claims as they happen instead of a fixed premium, with stop-loss capping the damage. Expected total {expected_total} against {fully_insured_premium}. The number that matters more is the worst case: maximum annual exposure is {max_annual_liability}. The saving is real but it is a risk transfer, not a discount.

• Eligibility Funding fully insured or level funded
• Eligibility At least 50

• incompatible level-funded
  Both are funding structures.
• incompatible rating-methodology
  Leaving fully insured removes the rating lever.
• enhances · rx-pbm-carveout
  Pharmacy carve-out only becomes possible once the employer holds claims risk.
• enhances · claims-audit
  Payment-integrity work needs the employer to be paying the claims.

🔴 The biggest in the catalog. State continuation drops away, Form 5500 / wrap obligations engage at the threshold, HIPAA privacy obligations change, and the OE notice list changes with them.

• Which Texas mandates fall away on self-funding, ENUMERATED (T3-1) — the corpus can only say 'preemption applies'.
• HIPAA privacy: limited vs full obligation (T3-2).
• Form 5500 threshold (T1-6 — stranded in the excluded Compliance tab).

Stop-loss restructuring

The medical claims aren't what moved — the stop-loss did, from {stoploss_premium_current} to {stoploss_premium_proposed}. Raising the specific deductible from {current_specific} to {proposed_specific} brings the premium back, and increases maximum exposure by {max_liability_change}. That is the trade, and it is the whole trade.

• Eligibility Funding self funded

• enhances claims-audit
  Both are self-funded cost-control levers and compound.

None — the funding type does not change. Worth saying out loud when weighing this against a bigger move.

• Texas stop-loss regulation / minimum attachment points (T2-1) — ⚠️ this play can propose an attachment point the state may not permit.

Reference-based pricing (RBP)

Instead of paying a negotiated discount off hospital charges, the plan pays a set multiple of Medicare — {medicare_multiple}. On {facility_spend_share} of spend going to facilities that projects to {projected_savings}. ⚠️ The trade is experiential, not financial: some providers will bill employees for the difference. This works when the employer will stand behind employees who get a surprise bill, and fails when they won't.

• Eligibility Funding self funded

• incompatible narrow-network
  RBP replaces the network premise rather than narrowing it.
• incompatible tiered-network
  Same reason — there is no network tier to steer within.
• enhances · direct-contracting
  Direct contracts with the facilities employees actually use neutralise RBP's balance-billing exposure.

Inherits everything self-funding brings, plus a materially higher member-communication burden at OE. The OE portal work is not optional for this play.

• The balance-billing model's interaction with the No Surprises Act — ⚠️ an adjacent-but-different question retrieval will answer confidently and wrongly.

Group captive

A group captive pools claims risk with other employers, so {employer} gets self-funded economics without carrying the volatility alone. Expected cost {expected_total} against {fully_insured_premium}. ⚠️ Two things make this different from an ordinary funding change: it asks for {collateral_requirement} in collateral, and it is a multi-year commitment — leaving early is expensive and the exit terms matter more than the first-year saving.

• Eligibility Funding fully insured or level funded
• Eligibility At least 50

• incompatible self-funded-stop-loss
  Both are funding structures.

Self-funded, so all of those effects. ⭐ Plus the multi-year commitment CONSTRAINS NEXT YEAR'S recommendation — the 'why not' record must carry that forward or next year's run will cheerfully re-recommend a change the employer can't make.

• Captive fee layers, collateral norms, distribution mechanics and EXIT TERMS — a play whose risk sits in the exit can't be recommended from material describing the entry.

Claims audit / payment integrity

Before changing anything employees experience, it is worth checking that what has already been paid was correct — eligibility, duplicate payments, coding, subrogation. On {annual_claims_spend} of annual claims an audit costs about {audit_cost}. ⚠️ Recoveries are not guaranteed, and any figure quoted before the audit is a guess. What is certain is that this is the only cost-control move on the table that no employee will notice.

• Eligibility Holds claims risk (a preference — can be reopened)

• enhances dependent-eligibility-audit
  Frequently run together; an eligibility finding often surfaces here first.

None on the checklist. ⚠️ A dependent-eligibility finding can remove people from coverage, which carries its own notice consequences.

MEC plan (minimum essential coverage)

Offering minimum essential coverage to the required share of full-time employees removes the {a_penalty_exposure} 'sledgehammer' exposure at {mec_total_cost} a year. 🔴 Understand precisely what it does not do: MEC is preventive-only. It is neither minimum value nor affordable, so it does NOT protect against the per-employee (b) penalty when someone takes a subsidy.

• Eligibility Must be ale

• requires mvp-companion
  MEC alone removes only the (a) penalty. Without the MVP companion this is half a strategy.
• incompatible ichra
  Different answers to the same question for the same population.

ACA reporting continues in full — the compliance surface does not shrink just because the plan did.

• The 4980H(a) penalty amount and its indexing (T1-7) — cited by four plays, and the corpus figures still need their own source.
• The 95% offer threshold and how full-time is counted.

MVP companion (affordable minimum-value plan)

Alongside the MEC plan, {employer} offers {mvp_plan} — meeting minimum value and priced to be affordable at {mvp_employee_cost} a month for employee-only coverage. That closes the remaining exposure: an employee taking a subsidy no longer triggers a per-employee penalty, because an affordable minimum-value offer was on the table.

• Eligibility Must be ale

• requires mec-plan
  This exists only as the second half of the MEC play.

⚠️ Affordability must be re-tested EVERY YEAR and whenever wages change — a recurring obligation that belongs on the ComplyDIY calendar, not in a broker's memory.

• 🔴 The minimum-value test itself (T1-3) — no document currently states it, and this play is named for it.
• The affordability percentage for the plan year, with its year, and the three safe-harbor methods.

ICHRA

Rather than sponsoring a group plan, {employer} contributes {ichra_allowance} a month toward coverage each employee buys individually. The employer's cost becomes a decision instead of a renewal outcome — {total_employer_cost} against {current_total_cost} — and it doesn't move unless {employer} moves it. ⚠️ The trade is that employees choose and manage their own plan, and how well that goes depends heavily on the local individual market.

No gates — available to any client.

• enhances · vary-by-class
  Classes are the mechanism ICHRA runs on — the incompatibility with the group plan is per CLASS, not blanket.
• incompatible qsehra
  Two answers to the same question.
• incompatible rating-methodology
  Leaving the group market removes the rating lever.

🔴 Different in KIND, not degree — the group plan's notice set is replaced by ICHRA-specific notices, the 90-day notice becomes a hard calendar obligation, and the checklist changes shape.

• The permitted class list and the minimum class-size rule (⚠️ which applies only to certain classes — easy to state as a blanket rule and be wrong).
• The 90-day notice requirement and its content; affordability against the benchmark plan; whether an affordable offer disqualifies the employee from a subsidy.

QSEHRA

{employer} has no group plan today. A QSEHRA reimburses employees tax-free for individual coverage and medical expenses, up to {annual_limit_self} for an individual and {annual_limit_family} for family coverage. At {qsehra_allowance_self} a month across {employee_count} employees that is {total_employer_cost} a year — a real benefit, with no renewal and no plan to administer.

• Eligibility Must not be ale
• Eligibility No group health
• Eligibility Fewer than 50

• incompatible ichra
  Two answers to the same question.

Creates a written-notice obligation with a deadline, and reporting. ⭐ For an employer that had no plan this is their FIRST compliance obligation — an honest ComplyDIY entry point.

• The annual limits WITH their tax year (indexed — never state without the year); the notice deadline; interaction with the employee's premium tax credit.

Medicare-primary coordination

{medicare_eligible_count} employees appear to be Medicare-eligible and the employer-size rules may make Medicare primary. ⚠️ This requires case-by-case review before anything is presented to the client — the anti-incentive rules restrict what an employer may offer or pay to move someone off the group plan, and the penalties are significant.

• Eligibility Medicare employees

• enhances · rating-methodology
  The source's own example — an employee moving to Medicare on a composite-rated group is exactly when to look at age rating.
• enhances retiree-hra
  Adjacent populations, same analysis.

MSP obligations and reporting. ⚠️ Getting this wrong is not a suboptimal recommendation, it is a penalty — the guardrail must run BEFORE presentation.

• ⭐ Well supported (~30 rows): the 20+/100+/ESRD tests, the anti-incentive prohibition with its penalty, Notice 2015-17. ⚠️ Verify the penalty figure carries its adjustment year.

Healthcare sharing arrangement

{arrangement} costs {sharing_monthly_cost} against {fully_insured_premium}. 🔴 It is not insurance. Members commit to share one another's costs; there is no guaranty fund, no regulator enforcing payment, and conditions may be excluded on grounds an insurance policy could not use.

No gates — available to any client.

• Texas regulatory treatment and the exemption relied on; ERISA status; ⭐ whether it is minimum essential coverage — almost certainly not, which would mean it fails at ELIGIBILITY for any ALE rather than at preference (T2-4).

Narrow / regional network

Moving to {narrow_network} takes {premium_savings} out of the renewal. The trade is access: {provider_match} of the providers this client named are in network. Nobody's benefits change — the list of doctors does.

• Eligibility Offers group health
• Eligibility Disruption allowed (a preference — can be reopened)
• Eligibility Must keep providers (a preference — can be reopened)
• Eligibility Ppo required (a preference — can be reopened)
• Market Narrow network available

• incompatible reference-based-pricing
  RBP replaces the network premise.
• enhances navigation
  Steering support softens the access complaints a narrower network generates.

SBC and OE communication change. No compliance consequence.

Tiered network

A tiered design keeps the full network but makes the preferred tier cheaper for employees — {tier1_cost_share} against {tier2_cost_share}, dropping premium {premium_savings}. {pct_current_utilization_in_tier1} of current utilisation is already in the preferred tier.

• Eligibility Offers group health
• Eligibility Disruption allowed (a preference — can be reopened)

• incompatible reference-based-pricing
  No network tier to steer within.
• enhances · navigation
  Without steering support the employee carries the burden of knowing the tiers.

SBC and OE communication. No compliance consequence.

Direct Primary Care (DPC)

DPC pays a flat {dpc_pepm} per employee per month for unlimited primary care — no copays, longer appointments, direct access — paired with {wrap_plan} for everything larger. Combined {combined_cost} against {current_total_cost}.

• Eligibility Offers group health

• enhances hdhp-migration
  Softens the access downside of a high deductible.
• requires hsa-with-contribution
  HSA compatibility must be resolved before pairing DPC with an HSA-qualified plan.

• ⭐ HSA compatibility is already answered in the corpus — do not re-research. Texas DPC regulatory treatment is Tier 3 (T3-4), deliberately low priority.

Direct contracting

{spend_concentration} of facility spend goes to {top_facilities}. At that concentration a direct contract is worth exploring — a negotiated rate with the places employees already go, rather than a discount off a chargemaster. Projected saving {projected_savings}. This takes months, not weeks.

• Eligibility Holds claims risk (a preference — can be reopened)

• enhances · reference-based-pricing
  Direct contracts remove exactly the balance-billing exposure RBP creates.

On-site / near-site clinic

With {site_headcount} employees at {primary_site}, a near-site clinic costs {clinic_annual_cost} — {cost_pepm} per employee per month, fixed. Unlike a plan change this does not flex with enrolment or claims: it is a commitment.

• Eligibility At least 100

• requires hsa-with-contribution
  ⚠️ Free or reduced-cost employer clinic care can affect HSA eligibility — verify before pairing.

• ⚠️ HSA interaction — employer clinic care can disqualify HSA eligibility depending on structure. Verify rather than assume.

Centers of Excellence / bundled episodes

For planned procedures like {common_procedures}, a bundled arrangement pays {bundled_price} against a local average of {current_avg_episode_cost} — {savings_per_case} per case including travel. It is worth {net_savings} only if roughly {assumed_case_volume} employees actually use it.

• Eligibility Holds claims risk (a preference — can be reopened)

• incompatible reference-based-pricing
  Conflicting pricing premises in most designs.
• enhances · navigation
  Employees do not find a COE on their own.

Navigation / advocacy / steerage

Navigation adds a service layer at {navigation_pepm} per employee per month: help choosing providers, understanding bills and managing complex care. Be clear about what is being bought — whether savings are guaranteed, measured, or projected varies by vendor and is the single most important question to ask before signing.

• Eligibility Offers group health

Telehealth / virtual-first

Telehealth gives employees {telehealth_description} at {telehealth_pepm} per employee per month. Check first whether the current plan already includes it — often it does, and the opportunity is communication rather than purchase.

• Eligibility Offers group health

• enhances hdhp-migration
  Mitigates the access complaints a high deductible generates.

• 🔴 HSA compatibility — the telehealth safe harbour for HDHPs has been temporary and extended more than once. ⚠️ Any statement of it without its effective period is unsafe.

Higher deductible / HDHP migration

Raising the deductible to {new_deductible} takes {premium_savings} out of the renewal. Employee exposure rises to {employee_exposure} — which is why this is usually paired with an account that puts some of the saving back.

• Eligibility Offers group health
• Eligibility Disruption allowed (a preference — can be reopened)

• enhances · hsa-with-contribution
  The classic pairing — the HSA is what makes the deductible tolerable.

SBCs change. ⚠️ Minimum value must be re-tested if the change is material, and grandfathered status can be lost.

Buy-down (same carrier, leaner design)

Staying with {current_carrier} but moving to {buydown_plan} saves {premium_savings} against the renewal. The network doesn't change — employees keep their doctors and their ID cards — so the trade is entirely in cost-sharing: deductible {current_deductible} → {buydown_deductible}, out-of-pocket max {current_oop_max} → {buydown_oop_max}.

• Eligibility Offers group health
• Eligibility Disruption allowed (a preference — can be reopened)

• incompatible copay-coinsurance-restructuring
  ⚠️ Same problem, same layer — presenting both reads as indecision.

SBCs change; grandfathered status may be lost.

• 🔴 The ACA minimum-value test (T1-3) — this play's guardrail says 'check minimum value before recommending' and no document states the test.

Add a lower-cost option (dual / triple)

Rather than changing {current_plan}, add {added_plan} alongside it. Employees who want the richer plan keep it and pay the difference; those who would rather keep the money take {added_plan}. Nobody loses a benefit. What the employer saves depends entirely on how many move: at {migration_low} take-up the saving is {saving_low}, at {migration_high} it is {saving_high}.

• Eligibility Offers group health

• enhances · active-enrollment
  Under passive renewal nobody moves and the play does nothing.
• requires defined-contribution
  Adding an option without setting contributions deliberately usually produces the opposite migration to the one intended.

An SBC per plan; OE materials must cover both.

Copay → coinsurance restructuring

Adjusting cost-sharing — {design_change_summary} — takes {premium_delta} out of the renewal without changing carrier, network or plan. Expected employee cost moves {expected_member_cost_current} → {expected_member_cost_proposed}.

• Eligibility Offers group health

• incompatible buy-down
  Same problem, same layer.

⚠️ Grandfathered status may be lost — permitted cost-sharing margins apply.

• Minimum value re-test (T1-3); grandfathered permitted cost-sharing margins (T3-3). Both unstated in the corpus and both guardrails on this play.

Spousal surcharge / working-spouse rule

{spouse_enrollment_count} spouses are enrolled, driving {spouse_claims_share} of claims. A {surcharge_amount} monthly surcharge on spouses with coverage available elsewhere projects {projected_savings}. This affects {affected_employee_count} employees directly and will be the most-discussed item at open enrolment.

• Eligibility Offers group health

• enhances · dependent-eligibility-audit
  Run the audit FIRST — verifying who is actually eligible is cheaper and fairer than surcharging everyone.

Notice obligations; §125 plan document changes; ⚠️ affordability re-test if it touches the employee's own cost.

• 🔴 T1-1 — ZERO corpus support. Permitted designs, notice, §125/§105(h) nondiscrimination, and whether the surcharge counts toward affordability. Do not present until sourced.

Active enrolment & plan migration

{recommended_play} only delivers {value_of_migration} if employees actually move, and under passive renewal most will not — they stay where they are. An active enrolment requires every employee to make a choice, with decision support to make it a good one. It is the difference between offering a strategy and implementing one.

• Eligibility Offers group health

• enhances · add-lower-cost-option
  The option only pays off if enrolment actually moves.
• enhances hdhp-migration
  Migration is the point.

⭐ Directly increases the OE portal's value — the natural Dunderbeck → portal handoff. Also surfaces eligibility problems, which can create notice obligations.

HSA with employer contribution

Moving to {hdhp_plan} saves {premium_savings}. Putting {employer_hsa_contribution} of that back into employees' HSAs means the deductible rises to {hdhp_deductible} but employees start the year with real money against it — net exposure {exposure_after_employer_hsa} rather than {employee_deductible_exposure}. The employer still keeps {net_employer_cost}, the contribution is tax-advantaged both ways, and what employees don't spend is theirs.

• Eligibility Offers group health

• requires hdhp-migration
  An HSA needs an HSA-qualified high-deductible plan.
• incompatible health-fsa
  A general-purpose health FSA disqualifies HSA eligibility. The limited-purpose form is the compatible one.

§125 plan documents if run through a cafeteria plan; W-2 reporting; ⚠️ comparability testing becomes an ANNUAL obligation, not a one-off.

• 🔴 T1-2 — §4980G comparability, and ⭐ the exception that decides the design: contributions made THROUGH a §125 cafeteria plan are exempt from comparability and fall under §125 nondiscrimination instead. That is what makes matching or tiered employer funding possible at all.
• Annual HSA limits and the HDHP minimum deductible / max out-of-pocket — with their tax year.

HSA, employee-funded only

{hdhp_plan} comes with an HSA employees can fund themselves through payroll, pre-tax, up to {annual_hsa_limit_self} individual / {annual_hsa_limit_family} family. It costs the employer nothing beyond payroll setup. Be realistic about what that means: with no employer seed, take-up depends almost entirely on education, and employees who don't fund the account simply have a higher deductible.

• Eligibility Offers group health

• requires hdhp-migration
  Needs an HSA-qualified plan.
• incompatible health-fsa
  A general-purpose health FSA disqualifies HSA eligibility.

• Limits and HDHP thresholds with their year; ⚠️ what disqualifies HSA eligibility — other coverage, general-purpose FSA, certain clinic arrangements, and the telehealth safe-harbour timing.

HSA funding pattern (lump sum vs per-pay vs matched)

{employer} contributes {annual_employer_hsa} per employee. How it is paid in matters as much as how much: funded per pay period, an employee's account doesn't cover the deductible until {breakeven_month}. Front-loading protects employees earlier at the same annual cost; the trade is that the employer funds sooner and cannot recover it if someone leaves.

• Eligibility Offers group health

• requires hsa-with-contribution
  A refinement of an employer-funded HSA, never a lead recommendation.

• ⭐ Comparability applies to the PATTERN, not only the amount (T1-2) — accelerated or matched funding is the case most likely to run into it, and the §125 route is the usual answer.

Back-end / deductible-gap HRA

Buy {high_deductible_plan} and self-fund the gap: employees see an effective deductible of {effective_deductible} because the employer reimburses the layer above it. Premium falls {premium_savings}; expected reimbursements are {expected_hra_spend}, so expected net saving is {expected_net_saving}. The number to hold onto is the worst case — if every employee hit the full layer it would cost {max_hra_liability}. Employees experience no change; the employer takes on variability in exchange for the saving.

• Eligibility Offers group health
• Eligibility Funding fully insured

• incompatible hsa-with-contribution
  ⚠️ A general-purpose HRA disqualifies HSA eligibility unless it is limited-purpose or post-deductible. Frequently missed.
• enhances buy-down
  The HRA is what makes the leaner plan tolerable.

🔴 The HRA is a self-funded group health plan in its own right — plan document, SPD, ERISA obligations, possible 5500 at the threshold, and COBRA applies to the HRA. ⭐ The clearest case of a play that looks like a plan-design tweak and is actually a compliance event.

• HRA integration rules; ⚠️ §105(h) nondiscrimination — ⭐ one of THREE places the same §105(h) decision recurs (HRA / MERP / FSA). Answer it once, apply it three times.

Integrated HRA

Pair {underlying_plan} with an HRA reimbursing {hra_reimbursement_scope} up to {hra_annual_max}. Employees get a richer experience than the plan alone; the employer pays only for what is actually used rather than pre-paying it in premium.

• Eligibility Offers group health

• incompatible hsa-with-contribution
  Unless limited-purpose or post-deductible.

Plan document, SPD, COBRA, possible 5500 — as the back-end HRA.

• Integration requirements; §105(h) — the same decision as the back-end HRA.

Excepted-Benefit HRA (EBHRA)

An excepted-benefit HRA gives each employee up to {ebhra_annual_cap} a year toward {permitted_expenses} — usable whether or not they enrol in the group plan. Maximum employer exposure {max_employer_cost}; actual cost is what employees use.

• Eligibility Offers group health

• enhances hsa-with-contribution
  An EBHRA does not disqualify HSA eligibility, unlike a general-purpose HRA.

Plan document; COBRA may apply.

• ⭐ The corpus is good here — EBHRA rows carry both the current and following year's cap. Verify the cap WITH its year and the permitted-expense list.

Health FSA / limited-purpose FSA

An FSA lets employees set aside up to {fsa_annual_limit} pre-tax for medical costs — saving employees roughly {employee_tax_saving_estimate} and the employer {employer_fica_saving} in payroll tax. {carryover_or_grace_design} determines what happens to unspent money, and is worth choosing deliberately rather than accepting the default.

• Eligibility Offers group health

• incompatible hsa-with-contribution
  General-purpose form only. The limited-purpose FSA is compatible with an HSA.

§125 plan document, nondiscrimination testing, COBRA may apply.

• The annual limit with its tax year; ⚠️ carryover vs grace period — you may have one or the other, not both; ⭐ the HSA interaction (general-purpose disqualifies, limited-purpose does not) — the highest-frequency mistake in this section.

Retiree coverage / retiree HRA

Retiree coverage costs {current_retiree_cost} today and is open-ended. A retiree HRA converts it into a defined contribution — {hra_allowance} per retiree, capping annual exposure at {capped_liability} — which retirees use toward individual or Medicare-supplement coverage. Pre-65 and Medicare-eligible retirees are different problems and need separating.

No gates — available to any client.

• enhances medicare-primary
  Adjacent populations, same analysis.

Its own notice and reporting obligations, separate from the active plan.

• Retiree HRA rules (⭐ a retiree-only HRA is not subject to the same integration requirements as an active-employee HRA — verify precisely); Medicare coordination; Part B/D premium reimbursement.

Rx / PBM carve-out

Pharmacy is {rx_share_of_total} of total spend — {rx_spend} a year — and is currently bundled with {current_arrangement}. Contracting pharmacy separately gives visibility into what is actually being paid and where rebates go. Projected saving {projected_rx_savings}. Employees keep their pharmacies; what changes is the contract behind the card.

• Eligibility Holds claims risk (a preference — can be reopened)

• enhances · specialty-drug-management
  You cannot manage specialty spend you cannot see.

• ⭐ The corpus is genuinely strong here (self-funded material) — verify pass-through vs spread pricing and rebate treatment are STATED rather than implied.

Specialty-drug management

Specialty drugs are {specialty_share_of_rx} of pharmacy spend — {specialty_spend} — concentrated in {top_specialty_drugs}. The levers are site of care, biosimilar substitution where clinically appropriate, and clinical management. Projected saving {projected_savings}. These decisions touch individual patients on serious therapies and belong with clinical oversight, not a spreadsheet.

• Eligibility Holds claims risk (a preference — can be reopened)

• requires rx-pbm-carveout
  Needs the visibility a carve-out provides.

• 🔴 Copay-accumulator / maximiser programmes are a live regulatory and litigation area — the highest 'confidently out of date' risk in this section. Verify the current position WITH its date; treat an undated answer as unusable.

Transparent TPA / PBM contracting

Administration currently costs {current_admin_fees}. A rebid tests three things beyond price: who owns the claims data, whether pricing is pass-through or spread, and how rebates are treated. Data ownership matters most — without it you cannot audit, cannot carve out, and cannot properly market the plan next year.

• Eligibility Holds claims risk (a preference — can be reopened)

• enhances · rx-pbm-carveout
  Data ownership is the precondition for carving anything out.

Vary by permitted employee class

This workforce divides into {proposed_classes}. Setting eligibility and contributions separately targets spend where it does most good — {contribution_summary_by_class} — for a total of {total_cost}. The classes must be bona fide and defined on a permitted basis.

• Eligibility Offers group health

• enhances · ichra
  Classes are the mechanism ICHRA runs on.

Nondiscrimination testing becomes an annual obligation; plan documents must reflect the classes.

• Permitted ICHRA class list + minimum class sizes; §105(h) eligibility and benefits tests; §125 nondiscrimination; carrier participation rules. ⚠️ FOUR distinct rule sets — the corpus must answer them separately.

Dependent-tier contribution design

Today the contribution is {current_contribution_summary}. Anchoring on employee-only coverage — covering {proposed_ee_only_pct} of the employee tier and {proposed_dependent_pct} of dependent tiers — costs {employer_total}, close to today, but changes what employees actually pay: {employee_cost_by_tier}. Affordability is tested on the employee-only cost, so this structure also affects {affordability_result}.

• Eligibility Offers group health

• enhances affordability-targeted-contribution
  The employee-only anchor is the cheapest route to affordability.

⚠️ Affordability re-test if the employee-only cost moves.

• ⭐ Affordability is tested on EMPLOYEE-ONLY cost, not family cost — verify this is stated plainly; it is what makes the anchor strategy work and is frequently misunderstood.

Defined contribution

The employer sets its contribution at {defined_contribution_amount} per employee per month across {plans_offered}. Budget becomes a decision rather than a renewal outcome — {employer_total} — and it does not move unless the employer moves it. Employees choose how much plan to buy with it.

• Eligibility Offers group health

• requires add-lower-cost-option
  Without multiple options a defined contribution is just a contribution change.

Affordability testing continues. ⚠️ As premiums rise, a fixed dollar means the employee share grows — which can break affordability in a LATER year.

• ⚠️ Affordability must still be tested for an ALE — fixing the dollar does not fix the compliance obligation, and the two are easy to conflate.

Contribution restructuring

Changing the employer/employee split from {current_split} to {proposed_split} moves {employer_saving} of cost without touching the plan, the network or anyone's benefits. Employee cost moves {employee_cost_change}.

• Eligibility Offers group health

⚠️ Affordability re-test for an ALE if the employee-only cost moves.

Affordability-targeted contribution

Under the {safe_harbor_method} safe harbor, the most that can be charged for employee-only coverage on {lowest_cost_mv_plan} is {max_affordable_contribution}. Today it is {current_ee_only_cost}. Moving to the limit costs {cost_of_change} and removes {b_penalty_exposure_avoided} of penalty exposure — usually a good trade, and one that has to be re-run every year.

• Eligibility Must be ale
• Eligibility Offers group health

• enhances dependent-tier-design
  The employee-only anchor is the cheapest route to affordability.

⭐ An annual, recurring obligation — re-test each renewal and on wage changes. This play should CREATE that calendar entry rather than assume the broker remembers.

• The affordability percentage for the plan year WITH its year (it changes annually and both current and next are needed at renewal); the three safe-harbor methods; the (b) penalty amount (T1-7); minimum value (T1-3).

Opt-out / cash-in-lieu credit

Offering {opt_out_payment} to employees who waive — where they have other coverage — redirects spend from premium to cash. At {likely_waiver_count} waivers that is {cost_of_payments} against {premium_avoided} avoided, netting {net_saving}. The catch that decides the design: an unconditional opt-out payment is treated as increasing what every employee effectively pays for coverage, which can break affordability. Structured as an eligible opt-out arrangement — requiring proof of other coverage — it is not.

• Eligibility Offers group health

• enhances dependent-eligibility-audit
  Both reduce spend by adjusting who is actually on the plan.

Affordability re-test; §125 documentation; ⚠️ proof-of-coverage collection becomes an ongoing administrative obligation, not a one-off.

• 🔴 T1-4 — the corpus row is FLSA-only. Unconditional vs conditional treatment, the affordability consequence, eligible-opt-out conditions, §125 constructive receipt. Do not present until sourced.

Dependent eligibility audit

{dependent_count} dependents are enrolled — {dependent_ratio} per employee. Audits routinely find some who are no longer eligible: ex-spouses, aged-out children, dependents who were never eligible. At {cost_per_dependent} each, removing them saves {potential_saving_range}. This is worth doing before any benefit reduction, because it takes cost out without taking benefits from anyone entitled to them. It does remove coverage from real families, so it needs a grace period, a clear appeals route and careful communication.

• Eligibility Offers group health

• enhances · spousal-surcharge
  Run this FIRST — cheaper and fairer than surcharging everyone.

⚠️ COBRA notices may be triggered; removals need documenting.

• ⚠️ COBRA consequences of removing an ineligible dependent — ⭐ the answer is not uniform and depends on WHY they are ineligible, exactly the nuance a thin retrieval will flatten.

Wellness / tobacco incentives

A {incentive_amount} differential tied to {programme_description} shifts cost toward employees whose choices drive it, with a reasonable alternative for anyone who cannot meet the standard. Two constraints shape the design: the incentive is capped, and for affordability testing the assumption is that employees do NOT earn a non-tobacco incentive — tobacco-related incentives are treated differently, and that difference is what makes the design work.

• Eligibility Offers group health

Notice requirements; ⚠️ ADA / GINA considerations if the programme involves health assessments or biometrics — ⭐ a different body of law from the HIPAA wellness rules, and an answer sourced from HIPAA would look complete and be incomplete.

• ⭐ The HIPAA nondiscrimination half is already well covered — do not re-research. 🔴 The affordability half is T1-5.

Small-group annual enrollment window

This group enrols {participation_pct} of eligible employees, below the {required_participation_pct} carriers normally require — which is why the standard market is closed. There is an annual window, {window_opens} to {window_closes}, during which coverage can be obtained without meeting that test. Two things to be clear about: it may require moving carrier, and it may only solve the problem for one year.

• Eligibility Funding fully insured

• requires active-enrollment
  The window buys a year; participation has to genuinely improve inside it or the group is back where it started.

⏳ Creates a dated follow-up obligation — participation must be at the required level by the next renewal. Belongs on the ComplyDIY calendar.

• 🔴 T1-8 — nothing in the corpus. The exact Texas window dates and conditions, which carriers participate, what relief it grants, and ⭐ whether the relief persists at the following renewal or lapses (that decides whether this is a solution or a deferral).

Keep incumbent (renew as-is)

{current_carrier}'s renewal on {current_plan} comes in at {renewal_increase_pct} ({renewal_increase_dollars} a year). We market-checked it: the closest alternative is {best_alternative}, saving {best_alternative_savings} — but that means a different network and new ID cards for every employee. For an increase of this size the savings don't justify the disruption. Recommend renewing as-is and revisiting next year.

• Eligibility Offers group health

• incompatible carrier-switch
  ⭐ The two answers to the same question — they must never appear as peers in one recommendation.

Nothing changes — the OE packet, SBCs and annual notices still go out. ⚠️ If the plan is grandfathered, confirm nothing in the renewal breaks that status.

Carrier switch

{proposed_carrier} comes in {savings} under {current_carrier}'s renewal on a comparable design. {must_keep_provider_match} of the providers this client named are in network, and formulary disruption affects {formulary_disruption}. Employees get new cards and, for some, a transition-of-care process.

• Eligibility Offers group health
• Eligibility Disruption allowed (a preference — can be reopened)

• incompatible keep-incumbent
  The two answers to the same question.

New SBCs, new plan documents, OE communication. ⚠️ Grandfathered status is lost on a carrier change.

Dual carrier / slice

Splitting between {carrier_a} and {carrier_b} lets each population keep the network that suits it — {population_split} — at {combined_cost} against {single_carrier_cost} with one carrier. It costs administrative simplicity: two renewals, two sets of materials, two service relationships.

• Eligibility Offers group health
• Eligibility At least 100

• enhances vary-by-class
  Class structure and carrier split usually follow the same population lines.

• ⚠️ Carrier participation requirements frequently make this impossible — check BEFORE it is ever surfaced, not after the client likes it.

PEO purchasing route

A PEO bundles benefits with payroll, HR and workers' comp under a co-employment arrangement. The comparison is {peo_total_cost} against {current_benefits_cost} plus {current_hr_payroll_cost} — and it must be made that way. Comparing only the health rate is how PEO decisions go wrong in both directions. The trade is control and portability: benefits come from the PEO's arrangement, and leaving means rebuilding.

No gates — available to any client.

• incompatible level-funded
  The PEO supplies the arrangement.
• incompatible self-funded-stop-loss
  The PEO supplies the arrangement.
• incompatible carrier-switch
  The PEO supplies the arrangement.

🔴 The compliance picture changes OWNER. Some obligations move to the PEO, some stay. ⚠️ Getting this boundary wrong means ComplyDIY shows a client obligations they no longer own — or hides ones they still do.

• Co-employment implications; ⚠️ who is the plan sponsor and what follows for ACA reporting and ERISA — ⭐ this determines what ComplyDIY should even show for a PEO client, so it matters beyond this play. Likely thin; verify.

Association plan / MEWA

{association_arrangement} quotes {quoted_cost} against {fully_insured_premium}. In Texas the first question is answerable rather than a matter of judgment: a MEWA must hold a TDI certificate of authority, and this arrangement {certificate_status}. Beyond that, the reserve standard it operates under is {reserve_standard} — which determines what stands behind employees' claims if the arrangement runs into trouble.

No gates — available to any client.

• 🔴 T2-2 — the FEDERAL frame only. ERISA §3(40) and the bona fide employer association test. ⚠️ Do NOT re-research Texas; it was sourced 2026-07-23.

Voluntary supplemental (accident, critical illness, hospital indemnity)

Moving to {hdhp_plan} raises employee exposure to {deductible_exposure}. {product_type} pays {product_benefit} on a qualifying event for {employee_premium} a month, employee-paid — covering roughly {gap_covered_pct} of that exposure for the events it applies to. It pays on specific triggers, not on medical costs generally, and it is only worth offering where the gap it addresses is real.

• Eligibility Offers group health

• incompatible deductible-gap-insurance
  Both close the same exposure; recommending both double-covers it.
• enhances hdhp-migration
  The gap this addresses is the one an HDHP creates.

• ⚠️ Excepted-benefit status and what preserves it; HSA compatibility (⭐ mostly fine, but product-specific — verify, don't generalise).

Deductible-gap insurance

Gap coverage insures {gap_covered} of the deductible for {gap_premium}. The honest comparison is against self-funding the same layer through an HRA at roughly {hra_equivalent_cost}: the gap policy is predictable and costs the same whether or not anyone claims; the HRA costs only what is used but varies. Which is better depends on whether this employer values certainty or expected cost.

• Eligibility Offers group health

• incompatible voluntary-supplemental
  Same exposure.
• incompatible back-end-hra
  ⭐ Same layer of cost, self-funded vs insured — pick one.
• incompatible hsa-with-contribution
  ⚠️ A gap product paying medical expenses below the deductible can disqualify HSA eligibility. A real trap, and the pairing is common.

Dental / vision

Dental at {dental_premium} and vision at {vision_premium} round out the package. These are visible, frequently-used benefits that employees notice — but they are small money against medical, and they should not be the answer to a medical cost problem.

No gates — available to any client.

⚠️ If NOT excepted benefits, they carry group-health obligations — the case worth flagging, since the default assumption is that they don't.

Life, disability, EAP / mental health

Basic life at {life_premium}, disability at {std_premium}/{ltd_premium} and an EAP at {eap_pepm} add {total_cost}. Disability is the most under-appreciated benefit in most packages — it protects the income the rest of the package depends on — and an EAP is usually the cheapest meaningful mental-health access an employer can add.

No gates — available to any client.

⚠️ Imputed income on employer-paid group life above the excluded amount — a real payroll consequence brokers routinely forget. ⚠️ Mental-health parity if the EAP is substantial enough to be a group health plan.

• The imputed-income threshold WITH its year; ⚠️ parity — an EAP providing significant treatment is a different animal from a referral service, and the distinction is easy to miss.