Templates That Do the Asking

The Renewal Timeline

Renewals are won at T-150, not T-30.

Carriers deliver renewals 60 to 90 days out because compressed timelines kill alternatives. Run this clock instead.

The Interrogation

12 questions for your broker. With the reasons behind them.

A good advisor answers these happily. An uncomfortable silence is also an answer.

1. What did you earn on our account last year, from every source?The 408(b)(2) disclosure makes this a legal right, not an awkward favor. Overrides and contingents shape advice.
2. What share of your book is self-funded, in captives, or on transparent PBM contracts?Their book is their comfort zone. If it’s 95% fully-insured BUCA, guess what gets recommended.
3. Show me our renewal’s underwriting build-up. What trend did they assume?A renewal is an argument, not a bill. You can’t argue with a number you’ve never seen decomposed.
4. Which alternatives did you test this year, and what did they quote?"The market is tough" without RFP receipts means nobody went to market.
5. What are our top five claims drivers, and what are we doing about each?If they can’t answer, they don’t have your data. Which is the real problem.
6. What does our PBM contract say about spread, rebate definitions, and audit rights?If the answer is a brochure word like "aligned" or "competitive," the contract says nothing good.
7. What’s our stop-loss contract type, and are there lasers or rate caps?A 12/12 with new lasers at renewal is a different product than a paid contract with a no-laser guarantee.
8. Are we compliant on the CAA items: gag clause attestation, RxDC, NQTL analysis?These are annual, federal, and yours. "The carrier handles it" needs to come with evidence.
9. What would you change about our plan if you owned our P&L?Invites the advisor to act like a fiduciary. The quality of the answer is the audition.
10. Which vendors pay you anything in connection with our plan?Wellness platforms, PBM coalitions, and tech vendors often share revenue with the broker who places them.
11. What’s our five-year cost trajectory if we change nothing?Compounding at 7-9% doubles your spend in roughly a decade. Make everyone look at that number annually.
12. When do we start next year’s renewal work?The only acceptable answer rhymes with "five to six months out." See the timeline above.

Contract Review

Seven PBM contract red flags.

Print this. Sit it next to the contract. Every flag below has cost some employer real money.

• "Rebate" is defined narrowlyIf admin fees, data fees, and GPO fees sit outside the definition, "100% pass-through" passes through a fraction of the money.
• No claim-level audit rights, or audits only by "mutually agreeable" firmsA right you can’t exercise isn’t a right. You want your auditor, your scope, claim-level detail.
• Different MAC lists for billing you vs. paying pharmaciesThat gap is spread pricing, contractually blessed.
• Discount guarantees measured "in aggregate" across all channelsRetail overperformance can paper over specialty and mail underperformance, where the dollars actually are.
• Mandatory use of the PBM’s own specialty and mail pharmaciesThe PBM steering claims to itself at prices it sets is a conflict, not a convenience.
• Termination requires 180+ days notice or carries penaltiesLong exit ramps exist to outlive your outrage. 60-90 days is achievable.
• No annual market check or contract reopenerThree-year terms without reopeners lock in year-one economics while the market moves.

Copy, Edit, Send

Two letters that change the conversation.

The first gets you your claims data. The second gets you your advisor's compensation picture. Both cite the law doing the asking. Have counsel review anything before it represents your company.

Subject: Claims data request for [Company Name] group health plan

[TPA / Carrier contact],

As plan sponsor of the [Company Name] group health plan (Group #[number]), we're requesting the plan's claims experience data for the trailing 24 months, delivered monthly thereafter:

1. Paid claims by month, split medical / pharmacy
2. High-cost claimant report: de-identified claimants over $50,000, with diagnosis category, paid-to-date, and status
3. Claims by service category (inpatient, outpatient, professional, ER, pharmacy)
4. Network utilization summary (in vs. out-of-network, by paid dollars)
5. Pharmacy detail: top 25 drugs by net plan cost, brand/generic/specialty mix, rebate amounts received

Under the Consolidated Appropriations Act, 2021 (ERISA Sec. 724), our service agreements cannot restrict the plan's access to de-identified claims and cost data, and we attest to that annually with CMS. We're also obligated as fiduciaries to monitor plan costs, which requires this data.

Please confirm by [date, 2 weeks out] when we'll receive the first delivery, and flag anything above you believe you cannot produce, with the specific contractual or legal basis.

Thanks,
[Name]
[Title], [Company Name]
Plan Sponsor / Plan Administrator

Subject: 408(b)(2) compensation disclosure request

[Broker / Consultant],

Ahead of our renewal, we're requesting the compensation disclosure required under ERISA Section 408(b)(2)(B) for brokers and consultants expecting $1,000 or more in compensation related to our group health plan.

Please provide, in writing:

1. A description of all services provided to the plan
2. All direct compensation you or your firm expects to receive
3. All indirect compensation: commissions, overrides, bonuses, contingent or supplemental compensation, persistency or volume awards, and payments from carriers, PBMs, wholesalers, or other third parties, with the payer and the arrangement described
4. Compensation expected in connection with placement of stop-loss, pharmacy, or any other coverage lines

As fiduciaries we're required to assess the reasonableness of plan compensation, and we can't do that without the full picture. Please deliver this before [date], as we'd like it in hand before any renewal discussion.

Thanks,
[Name]
[Title], [Company Name]

Before You Bind

The stop-loss quote checklist.

• Contract type stated plainly (12/12, 12/15, 15/12, paid)And matched to your runout exposure if you’re switching carriers.
• Laser policy in writing: current lasers, no-new-laser guarantee available?Price the guarantee. Sometimes it’s cheap. Sometimes that tells you something too.
• Renewal rate cap option quotedCaps your year-two surprise. Worth real money in a bad claims year.
• Aggregate corridor and minimum attachment basis125% of what, exactly? Enrollment drops shouldn’t silently raise your attachment point.
• Advance funding / monthly accommodation for specific claimsWithout it, you float six figures while reimbursement processes.
• Exclusions and caps mirror the plan documentA claim your plan covers but your stop-loss excludes is a gap with your name on it.
• Disclosure requirements and their deadlineLate disclosure of a known claimant can void coverage on exactly the claim you bought coverage for.

The Boring Armor

Plan document hygiene, in seven checks.

None of this is exciting. All of it is what a DOL auditor asks for in week one.

• Wrap plan document and SPD exist and are currentA carrier certificate alone usually fails ERISA. The wrap fixes it cheaply.
• Section 125 cafeteria plan document signed and datedNo document, no pre-tax payroll deductions. Auditors ask for the signature page.
• SMMs distributed for changes since the last SPD210 days after the plan year for most changes. 60 days for material reductions.
• Form 5500s filed for all applicable yearsMissing years? DFVCP before the DOL writes first.
• Annual notices batched and documentedCHIP, WHCRA, Medicare Part D, special enrollment, SBC. Keep proof of distribution, not just good intentions.
• Fiduciary file: meeting notes, RFPs, fee evaluations, 408(b)(2) disclosuresProcess is the defense. A thin file reads as no process.
• BAAs in place with every vendor touching PHITPA, PBM, broker analytics, wellness vendor. All of them.