Segal Company

Innovative Plan Design Strategy and Analysis

Effective plan design is the key to providing high-quality, cost-effective health care to multiemployer benefit plan members. Segal has extensive experience in the design and redesign of all health benefit plans, including medical, dental, prescription drug, vision, behavioral health, short- and long-term disability, life, accidental death and dismemberment, and flexible benefits.

Segal developed multiple strategies for designing plan rules such as rules of eligibility and waiting period, coordination of benefits, and participant cost sharing. We model the cost impact before a plan is changed (e.g. from a $10 copay to 20% coinsurance), so we can predict with accuracy how much the change will save a fund.

We use a number of strategies to enhance the health plans of our multiemployer clients. These include:

  • Participant cost sharing and contribution strategies
  • Multiple plan offerings/options
  • Targeted inner-tier networks
  • Specialty carve-out networks
  • Opt-out incentives
  • High-cost claimant-case management
  • Chronic illness utilization management
  • Exclusions and limitations
  • Eligibility rules (for active participant and retiree health coverage)
  • Retiree VEBAs

Value-Based Plan Design

Value-based plan design customizes plan design and management based on proven medical interventions, high-value therapies and efficacy, rather than providing a one-size-fits-all solution to coverage. These plans encourage treatments with evidence of clinical benefit and lowers financial and behavioral barriers to effective treatment. The plans also encourage participants to adopt healthy behaviors and help employers better manage plan costs. Examples of value-based plan design include:

  • Investing in wellness programs that are likely to have higher engagement rates and a meaningful impact on improving member health status
  • Broadening coverage for proven high-value, low-cost treatment options (e.g., generic drugs before brand-name, clinics before emergency rooms)
  • Targeted Utilization Review protocols for expensive therapeutic options and services that have little proven value or the greatest potential for abuse
  • Patient-Centered Medical Home, which fosters a relationship between primary care physician and patient, increases quality and consistency of care, and lowers costs
  • Lowering member copayments on high-impact drug therapy classes
  • Accountable Care Organizations, which are collectively accountable for quality and total per capita costs across the full continuum of care for a population of patients

Segal works with trustees and plan sponsors to develop, customize, and implement value-based initiatives – as well as communicate the changes to participants. We take into account the demographics of the members and dependents, plan experience, budget constraints, and the trustees’ benefits philosophy and goals.