Determine Market Segment
Determine Market Segment by averaging the total number of employees including full time, part time, seasonal and union in the year prior to the effective date. If the group has any affiliate or subsidiary companies that are required to be aggregated by the IRS, then all employees, seasonal and union from all aggregated companies will need to be added together.
A middle market group can have less than 51 employees enrolled.
1.1.19 -12.15.19 effective dates will use the average number of employees in 2018.
If the average in 2018 is 50 or less, than they would stay in the small group market for all of 2019. If the average number of employees is over 51 in 2019, then they would be the middle market in 2020.
Major Differences between Small Group and Middle Market
The middle market:
- is underwritten using the GRX database while the small group market is not
- has different plan options (non ACA) than the small group market.
- has composite only rates
- quotes start with a base quote and then firm rates are determined after submitting additional information and underwriting
- uses different employer forms for enrollment
- must accept the final rates before the policy will be activated (after underwriting)
Required information for groups with 51+ employees in 2018
How many total employees?
Full time, part time, seasonal and union from all affiliated or subsidiary companies required to be aggregated by the IRS?
Are there any 1099 employees?
1099 employees must work the minimum number of hours required for eligibility, receive majority of their income from the group and be treated the same as full time employees to be eligible to enroll.
Also, BCBS only allows 10% of total enrolled employees to be 1099.
Humana will allow an unlimited number of 1099 employees as long as there is at least 1 non owner W2 employee enrolled.
Where is the group’s headquarters located?
In order to enroll in a BCBS IL group plan, the group must be headquartered in Illinois and the authorized group representative signing the documents must be an Illinois resident.
How long has the group been in business?
This question will let the agent know if this is a new business or an established business. New businesses will require additional documents for enrollment.
Do they currently offer group insurance and/or ancillary products?
If yes, when is their renewal? Groups in this market normally only make carrier changes on renewal because renewal information is required for enrollment and quoting. The agent will need their renewal to get firm rates with other carriers.
If no, then this group is considered previously uninsured (PUG) and will not be medically underwritten. These groups will automatically receive a PUG rate up and possible participation (If below 75%) rate up as well. Participation uses all eligible employee enrollments as well as waivers regardless if the waiver is valid. Valid waivers are still included in the participation calculation.
If they offer ancillary products, which products and who is the carrier? Do they want competitive quotes?
If they do not offer ancillary products, this would be a good time to quote and discuss this with the group.
Are they fully funded, level funded or self-funded?
Fully funded – this means that the health insurance carrier is totally responsible for paying any portion of claims after the deductible, coinsurance or copayment have been met by the insured.
Level funded – this means that a portion of claims after the insured has paid their deductible, copayment or coinsurance will be paid from a claim fund up to a preset maximum per individual and per group.
Self-funded – this means the group is totally responsible for paying any portion of claims after the insured has met their deductible, copayment or coinsurance.
How many employees will be enrolling?
Since this market only uses composite rates, the quote should only include those employees who wish to enroll. Composite rates are calculated using only the quoted census. If the employees listed on enrollment are different than on the quote, the composite rates may change.
This estimate of enrolling employees will also show if there might be a participation rate up as well. The group needs to understand both of these concepts.
This is also why the group must accept the final rates because there is often rate changes after underwriting.
There are different quoting requirements based on number of enrolled employees so this is good to know ahead of time.
Are there any employees living outside of Illinois?
If yes – they can still be enrolled in the group, but there will be plan limitations due to network issues. The group will also need to provide payroll reports from each state for each employee outside of Illinois.
Information required for a base quote for Middle Market
Group’s legal name
Group’s headquarter address including street, city, state, county, zip code and phone number
SIC Code
Which carriers do you want quoted and fully funded or level funded?
Which ancillary products and carrier do you want quoted with benefit details?
All fields of the census must be completed based on the requested products to be quoted. Agents can either use the excel quote request form below or the online quote request.
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