Governed Care Pathways for Taft-Hartley Health and Welfare Funds
A documented process for evaluating how high-cost care enters the fund while preserving the existing administrator, consultant, network and benefit structure. Any governed pathway is separately scoped.
Trustees decide. Very little tells them what happened next
A joint board approves the plan, network, administrator and programs. Then care happens outside the board’s view, and the next signal may be a claims report.
The gap is not data. It is the missing record between what the board approved and what was applied when a participant needed care.
Documented process is already how a fund works
Funds already operate through minutes, adopted rules, documented exceptions and reconstructable decisions.
The approved rule
What the board adopted, on the record.
How it was applied
At the point a participant needed care.
The pathway decision
The resulting outcome, kept with its reason.
Governed entry is designed to create this record. Broader exception and pathway review expands as the evidence layer matures.
One fund. A clear starting point.
Not a plan redesign. Start with what the fund already has. Anything further is scoped on its own.
Establish the baseline
Review the fund's agreements and historical claims to see its starting position, data limits and open questions.
Scope the next step
Monitoring and opportunity review are scoped separately. Any governed pathway gets its own applicability review.
HealCo works alongside the fund’s existing administrator, consultant, network and trustee-led governance structure
Any pathway changes require the applicable approvals.
A record. Not a shield.
Documenting the decision process matters. What constitutes adequate process for a fund is a question for fund counsel.
A record of how the fund's approved rules were applied.
Four questions. No standard answers.
Do the fund’s agreements permit the data access needed to establish the baseline?
Who can adopt a pathway rule, and on what cycle can the board act?
Which administrators, consultants and counsel need to be in the room?
What findings or categories warrant further review?
Any pathway starting point depends on the fund’s claims pattern, participant geography and applicability review.
Start with the fund’s baseline
Begin with the fund’s agreements and available historical claims to establish the baseline and determine the appropriate next scope.