In general, a group health plan that covers employees of an employer that has 101 or more employees. Until 2016, in some states large groups are defined as 51 or more.
By most carrier standards, a large group would be an account with 51 or more eligible employees. However this term can be very subjective. A company with 51 eligible employees, but only a handful participating would still be considered a large group by most state insurance departments. However the broker and the group administrator may not agree. This is primarily because large groups are generally subject to medical underwriting, experience rating or having the rates based on the demographics -
There are various thresholds and requirements that pertain to large groups. For instance, most carriers require a participation percentage of usually 75% of net eligible employees to enroll to be considered for the marketing and the renewal of the account. The term ‘net’ factors the number of employees available after deducting those covered by their spouses and sometimes by Medicare or Medicaid.
Typically accounts are experience rated when over 100 employees are enrolled, however negotiated discounts are often contemplated on accounts with less than 100 enrolled if they run well with respect to claims. That is maintain a low medical loss ratio (MLR). Conversely, if an account is running poorly, renewal premiums often increase above industry trending rates. All this is subject to change with health care reform.
Loss information is usually only available on groups with over 100 enrolled. So how does a broker/agent effectively market an account when loss data is unavailable if the group has less than 100 lives enrolled but is still considered a large? All we can say is that there are other tools available.
By William F. Schaake, CIC, CRM © 2011, Revision 2016
“To ensure premium dollars are spent primarily on health care, the new law generally requires that at least 85% of all premium dollars collected by insurance companies for large employer plans are spent on health care services and health care quality improvement. For plans sold to individuals and small employers, at least 80% of the premium must be spent on benefits and quality improvement. If insurance companies do not meet these goals because their administrative costs or profits are too high, they must provide rebates to consumers.” Source: Healthcare.gov
Beginning in 2014, employers with 50 or more full-
Employers who offer health care coverage must pay the lesser of: $3,000 for each full-
Understanding Your Fiduciary Responsibilities Under A Group Health Plan by DOL.gov
Enrollment & Termination Processing
COBRA & FSA/HRA Administration
Aggressive Marketing on Renewal
Claims Disputes & Billing Reconciliations
Compliance and Regulatory Guidance
Direct Provider of Total HR Access
Electronic Document Sharing
Full Enrollment Services
Usually we get paid by the carriers, however under certain circumstances we can charge a fee for the services rendered. This provides an impartial approach during situations of competitive bidding. Most of the time we work through independent insurance agents and brokers. Generally a commission split is negotiated prior to the commencement of the insurance sale.
Emblem Health -
Horizon Blue Cross Blue Shield -
Delta Dental -
Principal Financial -
How long have they been in business?
Which carriers is the agency contracted with?
How is the office structured and is there a point person?
What ancillary services are provided?
How are documents saved and archived?
What other benefits does the agency provide?
Who services the groups and responds to their needs?
How are COBRA eligibles and participants handled?
What online services are offered and at what charges?
Are compliance and regulatory matters addressed?
Does the office work with outside experts for unique issues?
Are employee issues addressed by the agency or referred out?
Upon renewal, how aggressive is the marketing strategy?
How far in advance is the account marketed for renewal?
Who performs the enrollment meetings?
Is there assistance with the preparation the renewal?
Does the agency build in extra compensation for themselves?
For more details, see the following guideline for large groups>>
What is considered a large group and how is it rated?
Large Group Medical Insurance New Business Submission Guide
Understanding the Employer Shared Responsibility and ACA Reporting
Am I a candidate for a Self-
How will Large Group Health Insurance Plans Look Under Donald’s Trump’s Regime?
The Affordable Care Act has given Americans new rights and benefits, by helping more children get health coverage, ending lifetime and most annual limits on care, allowing young adults under 26 to stay on their parent’s health insurance, and giving patients access to recommended preventive services without cost.
Prior to enactment of the Affordable Care Act, sponsors of self-
The Affordable Care Act made a number of changes, with the result that sponsors of self-
This section is intended to provide information about this opt out provision. The information in this section will be of interest to state and local governmental employers that provide self-
For more information, go to: http://cciio.cms.gov/programs/marketreforms/nonfedgovplans/index.html
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Insurance & Employee Benefits