Editing Openai/695d4253-5060-8005-95db-586e777927f4 (section)

=== Assistant:  ===
==== - Legislative/regulatory changes: ACA/ERISA, HIPAA, MHPAEA, COBRA, transparency rules, surprise billing, state mandates, Medicare/Medicaid policy shifts that affect providers/prices, tax rules affecting HSAs/FSAs and employer contributions. ====
* Healthcare cost and market trends: local unit cost inflation, provider consolidation and contracting dynamics, price transparency effects, site-of-care shifts, new high-cost therapies (gene/cell), specialty Rx pipeline and rebates/PBM changes.
* Labor market / competitive benefits environment: what peer employers offer, recruiting/retention pressures, union negotiations, wage inflation (tradeoff between pay and benefits).
* Vendor landscape and performance: carrier/TPA capabilities, PBM and network changes, telehealth vendors, care management outcomes, service levels, and fee trends.
* Provider network/access environment: network adequacy, provider shortages, facility closures, referral patterns, quality/outcomes and patient experience.
* Population health and public health: epidemics/pandemics, behavioral health trends, substance use patterns, local health shocks affecting utilization.
* Litigation/enforcement climate: MHPAEA audits, fiduciary scrutiny (especially around PBM compensation), privacy/security enforcement and breach risk.
* Technology and cybersecurity: interoperability requirements, claims/eligibility transaction standards, cyber threats affecting vendors and employee data.

==== - Plan designs differ materially (deductibles, copays, coinsurance, OOP max, tiering), and even “similar” plans can produce different member costs depending on utilization. ====
* Different populations and geographies: demographics, morbidity, income, family mix, provider pricing levels, and market competitiveness vary.
* Funding and accounting differ: fully insured vs self-insured, stop-loss structure, reserves, and treatment of admin fees/rebates can vary.
* Network/PBM differences: contracted rates, formularies, utilization management, and care management programs affect value beyond benefit text.
* Employer contribution strategies differ: percent-of-premium vs flat-dollar, tiers, and wellness incentives change employee affordability and selection.
* Data limitations: incomplete disclosures on rebates/fees, differing measurement periods, and inconsistent metrics.

==== - Standardized actuarial value / richness metrics: estimate AV or expected paid-to-allowed using a common claim model. ====
* Benchmarking to a reference plan: normalize to a common plan design and price using the same allowed-cost basis.
* Scenario-based employee cost modeling: compare total cost (premium contribution + expected OOP) for standardized utilization profiles (low/medium/high, chronic condition scenarios) and by coverage tier (single/family).
* Total cost of coverage metrics: employer + employee spend, PEPM allowed and paid, admin load, and trend—adjusted for geography and demographics.
* Benefit scorecards: incorporate non-benefit features (network disruption, Rx coverage, UM rigor, care management, quality/service metrics) with weighted scoring.
* Peer surveys and broker benchmarks: use credible market surveys for prevalence of plan types and contribution strategies, adjusted for industry/region.