Bolton Health

Bolton provides best in class consulting to all stakeholders in the healthcare marketplace. We help our clients design, implement and manage cost effective programs that align with the strategic and financial goals of their organizations. Our experienced consultants assist clients by navigating the increasingly complex regulatory climate to ensure plans are competitive and compliant with constantly changing laws.

Areas of Health Expertise

We believe a key component to successful benefits management is creating and maintaining a long-term strategy that is aligned to your organization’s needs and goals. We have extensive experience designing competitive benefits programs and developing strategic plans that are focused on measurable goals, meaningful objectives and guiding organizational principles. During the strategic planning process, we analyze potential solutions under the lens of your specific organization and industry, while factoring in the needs of both the plan sponsor and the participants, by reviewing:

  • Existing strategic short and long-term goals
  • Industry trends, benchmarks and evolving labor market conditions
  • Claim cost and utilization trends
  • Budgets and financials
  • Alternative funding arrangements and delivery systems
  • Legal and regulatory developments
  • Eligibility and cost-sharing requirements
  • Emerging wellness, disease management and population health solutions
  • Administration, technology and communication requirements

Once complete, we work closely with you through execution and beyond to ensure ongoing performance management and the continued relevance of our advice and solutions.

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For many clients accurate benchmarking is central to developing a long-term strategy– identifying best practices, prioritizing opportunities for improvement, and enhancing performance relative to employee and organizational expectations. Based on statistical market comparisons, and an in-depth analysis of your current benefits, we can help your organization effectively manage the ever changing terrain of the evolving benefits landscape.


During our process, we provide a detailed benefits analysis of your health and welfare programs including healthcare, pharmacy, dental, vision, disability, and life insurance where we:

  • Examine existing plan design, costs and funding arrangements
  • Utilize both published and proprietary survey data to determine competitive position
  • Evaluate plan communications, including employee understanding and engagement
  • Identify deviations between organizational and employee objectives vis a vis the current benefits structure
  • Prepare reports and present findings to leadership on the competitiveness and adequacy of your organization’s benefit plans
  • Provide recommended changes and new solutions for consideration


Executive interviews are a useful tool that provides valuable information and insights from executive leadership. Done correctly they will help you assess the baseline level of awareness, understanding, and appreciation regarding current programs by:

  • Uncovering stakeholders’ experiences, perceptions, goals and expectations
  • Identifying and gathering feedback on key issues and concerns
  • Establishing the reasons why certain benefits are in place and whether they need to be maintained or modified


Many organizations also use focus group or survey research to understand employee perceptions about various human resource issues and benefits, and to gauge employees’ reaction to potential changes. Surveys and focus groups help you understand employee perceptions of the current benefit programs offered, assess specific employee needs, and provide employees with the ability to offer suggested solutions to problems. We are experienced in facilitating group conversations to uncover valuable employee feedback without creating unrealistic expectations.

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Bolton Health’s Actuarial Group was formed in 2012 with the guiding vision to provide best-in-class actuarial and strategic consulting to stakeholders in the healthcare marketplace, as well as to complement our core employee benefits consulting practice. Our experienced consulting actuaries have comprehensive knowledge of pricing and reviewing Medicare Advantage and major medical insurance products and navigating the Affordable Care Act (ACA), Federal regulations and state laws. We provide client-centered consulting services such as:

  • Medicare Advantage:  Our team has been engaged in the Medicare Advantage (MA) and Part D (PD) space since each programs’ inception.  We provide our clients with the spectrum of Medicare-related services, including: full-service strategic development of MA and PD bids; analytical support monitoring the Medicare business to identify cost drivers; report preparation examining actual versus expected results; tracking provider performance metrics; estimating PD liabilities; development of MA and PD bids; and much more.  In addition, Bolton Health provides industry insight through speaking engagements as well as employee training tailored to fit the needs of each organization. Bolton Health is also highly skilled in a peer review role for clients who develop their own MAPD bids, examining both the development of the BPTs and the supporting documentation to ensure both are meeting CMS’ standards.
  • Custom Analytics, Models and Reporting:  We utilize a suite of tools for pricing, reserving and reporting that serves as a baseline for developing customized client-specific tools to answer the questions being asked and the goals to be met.  We pride ourselves on tailoring our models to the needs of our clients versus a one-size-fits-all approach.
  • Legislative and Regulatory Impact Analyses:  We have extensive experience interpreting, evaluating and implementing healthcare reform.  Recent engagements include: accountable care organization (ACO) implementation; CMS Bundled Care Payment Program evaluation and analytics; Intellectual and Developmental Disabilities (IDD) waiver utilization analysis; interpretation of ACA regulations and state rate filing reviews; and assisting a startup technology company decipher the nuances of health care while they develop innovative health care cost management ideas.  Our team holds a wide breadth of knowledge that spans the commercial, Medicare and Medicaid markets.
  • Unpaid Claim Liabilities / Year-End Opinions:  Bolton Health maintains qualified actuaries to render actuarial opinions with respect to year-end claims liabilities and currently serves as the appointed actuary for our clients.  The team’s experience includes setting liability estimates for various lines of business (Medicare, Medicaid, large group, small group, etc.) as well as the liabilities associated with Medicare Part D coverage.  Bolton Health has an internal reserve model that allows for the consideration of the following, to name a few: large claims, work days, seasonality, trend, claim credibility and the average claim duration.  To develop the most appropriate estimate of liabilities, our consultants work closely with each client to understand the client’s claims patterns, differences across lines of business, and management practices.
  • Risk-Based Contracting:  Risk-based contracting services on behalf of MCOs, providers and state insurance departments, including: contract development and monitoring; feasibility studies; and evaluation and calculation of final payment to payors and providers.  Our team is an ideal partner for these services as we understand the nuances of all lines of business, have extensive experience interpreting and communicating specific contract language and have worked for both payors and providers.

We passionately believe that our investment in independent and professional healthcare actuarial services is one of the key components that sets Bolton Health apart from the competition.

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We collaborate with prestigious healthcare leaders such as Johns Hopkins Healthcare Solutions to connect the marketplace to their innovative, evidence-based products and services. We work with clients and partners to bring these and other programs to the workplace to improve population health, while meaningfully impacting employee productivity through improved engagement and wellbeing. Our work begins by analyzing which population health programs work best for your employees, and then train your team on implementing them to improve outcomes. Services and solutions include:

  • Data mining, warehousing and predictive analytics
  • Innovative consumer-driven and value-based plan designs
  • Engagement platforms to support program elements and participant communications
  • On-site health and wellness clinics, and telemedicine
  • Cancer, diabetes, and chronic health condition management
  • On-site screening, activities, health promotion and coaching
  • Proactive participant outreach and care management
  • Behavioral health assessment and integration
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As an independent benefits consulting firm, Bolton can assist you in shopping for the best plans with the lowest possible costs. We provide cost-effective solutions that help you and your employees manage costs by creating competitive request for proposals (RFPs) and a bid review process that accurately compares price, access, coverage, quality, and other important criteria to help you choose a plan that works for your budget, business, and employees. We have experienced healthcare underwriters and actuaries (many of whom used to work for insurance carriers) that understand rate development and the renewal process, so that you get the best possible deal and guarantees over the log-term. We have licensed independent insurance brokers that are certified to offer plans, support and service by:

  • Obtaining an individual or small group policy directly through the carrier (we work with all licensed carriers)
  • Shopping for Coverage using the State and Federal Health Insurance Exchanges
  • Evaluating private exchanges
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The pharmacy consulting process helps to improve value and lower spend through a comprehensive clinical and risk management approach that includes:

  • Expert guidance – with attention given to cost, quality and performance of program
    • Strategic planning
    • Risk Management
  • Evaluation of PBM contracts and programs
    • Clinical Prior Authorizations
    • Specialty Rx programs
    • Utilization Management programs
    • Opioid Management programs
  • Negotiation of PBM contracts
    • Annual Pharmacy Benefit Program Reviews
    • Annual Audits
      • PBM Contract Pricing Guarantees
      • Plan Design Compliance
  • Evaluation of programs available outside traditional PBMs
  • Support for Client and Member Service Issues
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A knowledgeable, proven partner is critical to the success of voluntary benefits within your organization. We offer an end to end voluntary benefits solution unmatched in the industry, managed by career professionals who are hands-on involved with every client. We have the insight and experience in providing voluntary benefit solutions that allow you to reduce benefit costs, while strengthening your overall employee benefit programs. Working with us, you will find a knowledgeable, proven partner who will ensure your success with both your core and voluntary benefits goals. What can voluntary benefits solutions do for you? Voluntary benefits are the key to constructing and delivering a benefits package with affordable and comprehensive insurance protection by adding significant value with little to no cost to the employer.


  • Plan assessment and gap analysis
  • Data processing
  • Product selection and marketing
  • Ongoing employee customer service
  • Pre-enrollment communication
  • Sole source contact for human resources
  • Implementation and enrollment
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Dependent Eligibility Verifications and Healthcare Claims Audits are conducted to drive long-term health plan objectives, as well as to receive immediate, short term returns or a one-time recovery of funds, and are one of the best ways to demonstrate fiduciary prudence. By making use of these periodic audits, employers can more easily control the rising costs of employee benefits, while protecting the program from purposeful fraud or accidental waste. These audits also protect your workforce from unnecessary expenses. We work with many respected experts in the healthcare claims audit field, and can help you identify the best solution given your particular needs. In addition, we have a proprietary, comprehensive and secure dependent verification process that takes this sensitive issue out of the client’s hands. We have been very successful in removing ineligible dependents, thereby saving clients significant health care costs. We also provide ongoing dependent verification services for organizations that wish to outsource this task.

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We assist clients to satisfy their fiduciary duties by ensuring their vendors offer the best combination of cost, access, quality, and financial security. We manage the entire process, beginning with the development and administration of the RFP, answering vendor questions, analyzing vendor responses, conducting site visits and finalist interviews, reviewing contracts, and negotiating best and final pricing and performance guarantees. Once your service providers have been selected, we manage ongoing service provider relationships, advise on contracts, review provider service levels compared to performance guarantees, and resolve administrative, service and claims issues.

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The employee benefits legal and regulatory environment is complex to say the least. As such, employers often struggle to keep up with the ever-changing, and often confusing, employee benefit compliance and disclosure requirements. While you have a fiduciary responsibility to ensure that your benefits are administered and maintained in accordance with applicable laws, our goal is to help you limit compliance and operational risks by providing the support you need to focus on other matters. These services include:

  • Compliance audits of current documentation, practices and policies
  • Client seminars and private briefings on relevant compliance issues, including ERISA, HIPAA, ACA, COBRA, FMLA & AHCA guidance
  • Development and distribution of compliance alerts, legislative updates, and education
  • 1094 and 1095 reporting and regulatory tracking
  • Plan documents, summary plan descriptions and related notices
  • Discrimination testing and Form 5500 preparation
  • Medicare Part D Retiree Drug Subsidy (RDS) consulting
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Retiree medical costs are a significant and ever-increasing exposure. Whether you need assistance with your OPEB valuation, are struggling with the new and complex GASB rules, or are looking for innovative ways to manage expense, Bolton can help you develop an effective strategy. When assessing your overall medical program there are a range of options available to manage retiree costs, including:

  • Fixed Dollar Subsidies Coupled with Private exchanges
  • Prefunding Approaches
  • Medicare Advantage Plans
  • Employer Group Waiver Plans (EGWPs)
  • Defined Contributions to Health Reimbursement Accounts (HRAs) or VEBAs
  • Social Security Disability audits for pre-65 retirees
  • Audit of your plan compared to peers (minimum years of service required, subsidy by years of service, dependent subsidy, etc.)

These options can have minimal or significant impact on your retirees. Bolton is highly skilled in evaluating alternatives and providing solutions that help you manage and fund your retiree medical program while controlling current costs, risk exposure and future liability.

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Bolton can help you automate your employee benefits enrollment and administration to streamline efficiencies, reduce overhead, and provide an enhanced employee experience. Our comprehensive approach combines innovative enrollment technology and personalized services to ensure successful enrollment and employee engagement that aligns with your organizational goals. We look for opportunities to improve processes, improve employee education and appreciation, and accomplish your key HR initiatives. Our Customized Enrollment Solutions include:

  • Annual Open Enrollment Consultation and Support
  • Year-round New Hire Onboarding Support
  • Benefits Billing and Reconciliation
  • Customizable Technology Platforms
  • Communication Tools
    • Communications Strategy
    • Benefit Guides
    • Traditional Print Materials
    • Email Campaigns and Embedded Custom Videos
    • Text Messaging
    • Mobile Apps
    • Call Center Support
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