What Happens During a Plan Design Audit?
Most employers receive renewal quotes 30 days before their policy expires and are forced to make rushed decisions based on incomplete information. A Plan Design Audit flips this dynamic—giving you 60-120 days to understand your current program, identify cost drivers, and explore alternatives before renewal pressure begins.
The Four-Phase Audit Process
A comprehensive Plan Design Audit follows a structured methodology designed to uncover opportunities that traditional rate shopping misses. Here’s what happens at each stage:
Phase 1: Data Collection & Review
Timeline: Week 1
We gather and analyze your current insurance and benefits documentation to establish a baseline understanding of your program structure.
What We Request:
✓ Current policy declarations and coverage summaries
✓ Last 24-36 months of renewal history and premium changes
✓ Claims experience summaries (if available)
✓ Employee census data and participation rates
✓ Current benefit plan documents and Summary Plan Descriptions
Phase 2: Cost Driver Analysis
Timeline: Weeks 2-3
We identify the specific factors driving your insurance costs—many of which aren’t visible in renewal quotes or carrier presentations.
What We Analyze:
✓ Plan Structure: Deductibles, copays, coinsurance, out-of-pocket maximums, and network design
✓ Utilization Patterns: High-cost claimants, chronic conditions, pharmacy spend, and emergency room usage
✓ Funding Method: Whether fully-insured, level-funded, or self-funded arrangements would better align with your risk profile
✓ Carrier Pricing: Administrative fees, risk charges, and profit margins embedded in premiums
✓ Classification Accuracy: For commercial insurance, ensuring operations and payroll are properly classified
Phase 3: Design Alternatives & Modeling
Timeline: Weeks 3-4
Based on the cost driver analysis, we model alternative plan designs and funding strategies to show projected savings and risk exposure.
What We Model:
✓ Plan Design Variations: Different deductible/copay combinations that maintain coverage quality while reducing premiums
✓ Funding Strategy Comparisons: Side-by-side analysis of fully-insured, level-funded, and self-funded options with actual cost projections
✓ Pharmacy Optimization: Formulary changes, specialty drug management, and alternative pharmacy networks
✓ Network Alternatives: Narrow networks, reference-based pricing, or direct primary care arrangements
✓ Wellness & Prevention: Programs that address identified utilization patterns and chronic conditions
Phase 4: Presentation & Decision Support
Timeline: Week 5
We present findings in a clear, side-by-side comparison format that allows you to make informed decisions without pressure or confusion.
What You Receive:
✓ Executive Summary: One-page overview of current state, identified opportunities, and recommended actions
✓ Cost Comparison Matrix: Side-by-side analysis of current plan vs. alternative designs with projected savings
✓ Risk Assessment: Clear explanation of trade-offs and risk exposure under each option
✓ Implementation Timeline: Step-by-step roadmap if you choose to make changes
✓ Employee Communication Materials: Draft communications explaining any plan changes to your team
Real Example: Manufacturing Company Audit
A 75-employee manufacturing company in Pennsylvania came to us with a 12% renewal increase on their Blue Cross plan. Their broker recommended accepting the increase or switching to a different carrier with a 7% increase.
Our Plan Design Audit revealed that their plan design hadn’t been reviewed in five years. They had a $500 deductible with $20 copays—generous coverage, but driving unnecessary utilization for routine care.
Audit Findings:
✓ 80% of claims were for routine office visits and generic prescriptions
✓ Only 3 employees had claims exceeding $10,000 annually
✓ Emergency room usage was 40% higher than industry average for their demographic
Recommended Solution:
✓ Moved to a $1,500 deductible plan with HSA contributions ($1,200 employer-funded)
✓ Implemented telemedicine benefit to reduce ER visits for non-emergencies
✓ Switched to level-funded arrangement for transparency and potential year-end refunds
Result:
22% premium reduction compared to their renewal quote, with employees receiving better catastrophic coverage through lower out-of-pocket maximums. The company received a $28,000 refund at year-end when claims came in below projections.
What Makes This Different from Traditional Renewal?
Traditional renewal processes focus on one question: “Which carrier has the lowest rate?” A Plan Design Audit asks different questions:
✓ Why are our costs increasing? Not just “how much,” but what specific factors are driving premium growth
✓ Is our plan structure appropriate? Are we overpaying for coverage that employees don’t value or underpaying for protections they need?
✓ What alternatives exist? Beyond carrier shopping, what funding strategies or plan designs could better align with our objectives?
✓ How do we control long-term costs? Not just this year’s premium, but sustainable strategies for the next 3-5 years
Is There Any Obligation?
No. The Plan Design Audit is informational and educational. Many employers use it to understand their options before deciding whether any changes are needed. Some choose to implement recommended changes. Others use the findings to negotiate better terms with their current broker or carrier. Either way, you gain clarity that wasn’t available before.
The only requirement is providing the documentation needed for analysis and being willing to consider alternatives to the status quo. If you’re satisfied with your current program after seeing the audit results, there’s no pressure to change anything.
Ready to See What's Possible?
These satisfied clients started with a simple,
no-obligation Plan Design Audit...
These satisfied clients started with a simple,
no-obligation Plan Design Audit...
What makes Horizon Insure Business Group different from other insurance brokers?
Most insurance brokers focus on shopping rates at renewal. Horizon Insure Business Group takes a plan design approach—reviewing how your current insurance and benefits are structured to identify smarter ways to control costs and improve coverage before renewal decisions are made.
Do you only work with businesses in Pennsylvania and New Jersey?
Our primary focus is serving employers in Pennsylvania and New Jersey. This local focus allows us to provide more tailored guidance and hands-on support for regional regulations, carriers, and employer needs.
What is a Plan Design Audit?
A Plan Design Audit is a structured review of your current insurance and employee benefits program. It identifies cost drivers, coverage gaps, and design opportunities so you can make informed decisions before renewal—without pressure to change brokers.
What size businesses do you typically work with?
No. The Plan Design Audit is informational and educational. Many employers use it to understand their options before deciding whether any changes are needed.
Do I have to switch brokers to get a Plan Design Audit?
We primarily work with small to mid-sized employers, typically ranging from 25 to 250 employees, who want more control over insurance costs and benefits strategy.