| name | benefits-plan-design |
| description | Design a group employee-benefits package as a system: plan types per line (medical/dental/vision/life/disability), plan-type mechanics (HMO/PPO/HDHP+HSA, deductible/coinsurance/OOP-max), and the funding decision (fully-insured vs self-funded vs level-funded) sized to the group, with the ACA/ERISA obligations named — educational scaffolding, not advice. |
Benefits Plan Design
Start from the workforce, not the brochure
Design around the population: size, age/family mix, income, and how they actually use care. The package is a system — medical, dental, vision, life, and disability are chosen together, and the gaps between them are where members get hurt. Disability income is the most under-bought line; flag it every time.
Plan-type mechanics, not just premium
Frame the trade across HMO / PPO / EPO / POS / HDHP+HSA: network breadth vs cost-share vs premium. Optimize the member's total cost of coverage (deductible + coinsurance + OOP-max), not the headline rate. An HDHP without funded employer HSA contributions is a cost-shift, not a benefit — pair it or say so.
Funding is a risk decision
Fully-insured buys predictability; self-funded keeps the risk and upside (needs stop-loss + cash-flow tolerance + a credible group); level-funded is the middle path. Size the choice to the group, not a vendor's pitch. Never self-fund just to dodge one bad renewal — it's a multi-year posture. (See the funding decision tree in ../../knowledge/.)
Contribution & eligibility structure
Set the employer/employee/dependent split, tiers, and waiting periods — and check ACA affordability and minimum value against the employer-shared-responsibility rules. [verify-at-build] the current-year ACA thresholds.
ACA / ERISA basics (the floor)
Name the obligations the package triggers: ALE / employer-shared-responsibility, affordability, minimum value, ERISA plan documents / SPD, Section 125 framing, non-discrimination concerns to flag for counsel. These are constraints, not afterthoughts.
Output
A benefits-program brief: the package per line (with rationale), the funding recommendation with the conditions that would change it, the contribution structure, and the ACA/ERISA obligations triggered — all flagged as educational, with a broker/ERISA-counsel sign-off step. Hand rate adequacy to underwriting-and-actuarial-analyst and enrollment/filings to enrollment-and-compliance-lead.
