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AGENTS AND THE FUTURE Presented by Don Goldmann President-Elect of the National Association of Health Underwriters Vice President of Word & Brown University CAHU CE Course 289511 North Coast AHU Annual Symposium September 10, 2014. What’s an insurance broker look like?.

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Presented by Don Goldmann

President-Elect of the National Association of Health Underwriters

Vice President of Word & Brown University

CAHU CE Course 289511

North Coast AHU Annual SymposiumSeptember 10, 2014

what we will discuss today
What we will discuss today

Today’s Agenda

  • The Historical Evolution of Broker Distribution Systems and Underwriting
  • Upcoming Pressures on the System
  • Articulating Broker’s Place in the System
a broker is 1 3 of the underwriting system
that a financial service provider uses to decide if a customer is a good risk for their product.

Bank underwriters decide on mortgage or credit loans.

Investment underwriters decide whether to invest capital.

Insurance underwriters decide on insurance policies

A broker is 1/3 of the underwriting system

Underwriting is a three part process . . .

  • An health insurance acturary, through data analysis, defines what a “good bet” looks like.
  • A broker seeks out and brings in the “right” kind of “bettor”.
  • The underwriter is the person who decides if the “bettor” fits the actuary’s model for being good.
earliest underwriting
The earliest professional and organized underwriting systems were created for two things - stocks and insurance.

Primarily property such as ships

1694 – Hugh the Elder Chamberlen

Edward Lloyds’ coffee house, catered to the shipping industry which drew into the facility the earliest insurance underwriters who backed shipping traffic.

Earliest Underwriting
the unique american model
Earliest American distribution was by “field underwriters” who did risk analysis and selling

Civil War “Death and Dismemberment” policies started the splitting of various underwriting tasks

A bi-costal American required a bi-costal financial system

WWII reshaped the American workforce and expanded medical care in the workplace

Post WWII veterans benefits, economic expansion and wage/price controls

The Unique American Model
modern brokerage operation in california
State’s view of “health insurance”


Worker’s Compensation

Life & Disability or P&C/Disability

HMO versus Indemnity

Agent versus broker

Carrier representative

“Independent” broker

General Agent

Third Party Administrator

Roles of the broker

Plan Design

Field Underwriting

Employment Strategiesand Service

Advocate and Defender

Modern Brokerage Operation in California
upcoming pressures
Upcoming Pressures
  • Latest On Employer Reporting and IRS Forms
  • Incorrect IRS Premium Tax Credit Recovery
  • Update on Discrimination Testing
  • California Employer New Hire Waiting Period
  • California Rate Regulation Initiative
last year showed us the game s easier without rules
Last Year Showed Us –The Game’s Easier Without Rules
  • The goal will be achieved by 12/31/2013
  • The goal will be achieved by 2/15/2013
  • The goal will be achieved by 3/31/2013
  • The goal will be achieved by 4/15/2013
it s even easier when only others have to follow the rules
It’s Even Easier When Only Others Have To Follow The Rules




  • The goal is xxx members by 12/31/2013
  • Xxx by 1/1/5/2013
  • Xxx by 2/15/2013
  • Xxx by 3/31/2013
  • Xxx by 4/15/2013
  • WE WIN!
the rules of employer responsibility reporting
The Rules of Employer Responsibility Reporting
  • Goals
    • Verify employers and individuals meet mandates
    • Verify that individuals receiving premium tax credits deserve them
  • Precisely who files currently unclear
    • Penalties start for employers with 100 or more FTE 2015
    • Penalties start for employers with 50 or more FTE 2016
    • Forms verify individual employee claims to tax credit and therefore, employer penalty phase may be irrelevant
  • Carrier reports fully insured individual policies and sub-50 employer enrollment; but not who was offered
reporting form 1095 c
Reporting Form 1095-C
  • Filed for every employee “eligible” for coverage
  • Who was “eligible” will be critical as 1095-C will be used to determine if penalty A or B applies
  • “Safe Harbor” rules of 70% for 2015 and “5 OR 5%” for 2016 will apply and be subject to audit
  • Several codes will be used to identify:
    • If coverage was offered during a given month
    • Extent of coverage
    • Employee share of cost
    • Part III filed by self funded employer and fully funded carrier
  • Like a W-2, employees will get a 1095-B and/or a 1095-C
transmittal form 1094 c
Transmittal Form 1094-C
  • Summarizes all of the 1095-C
  • A copy of each 1095-C sent to the employees gets sent with it
  • Electronic transmission expected
  • While the forms are not final and there are obvious textual errors in the draft, the draft formats provide a guide as to what will likely be required
background of possible premium tax credits
Background of PossiblePremium Tax Credits
  • Estimated 1.7 million possible inaccurate premium tax credit calculations
  • IRS could verify 2013 filings
  • If the 2014 estimate claimed was 10% different, reviews were to be done, but none were done until summer of 2014
  • Zero verifications of a lack of employer-coverage for MEC, minimal value or affordability
  • ACA penalties and tax credits are not handled the same
incorrect irs premium tax credit recovery
Incorrect IRS PremiumTax Credit Recovery
  • Jackson Hewitt Tax Service estimates that a third of filers with premium tax credits will owe the IRS
  • Average national tax credit is estimated to be $3,168
  • Average tax refund is $2,690
  • 1040EZ Form cannot be used for such tax credits
  • Individual mandate exempt from liens or levies
irs premium tax credit recovery caps
IRS Premium TaxCredit Recovery Caps
  • Tax credits are subject to all forms of recovery
  • Reduction of tax refund is the first resort
  • Collections are capped for some –
    • Individuals less $22,980 - $300 in repayments
    • $22,980 to $34,470 - $750 in repayments
    • $34,470 to $45,960 - $1,250
    • Above $45,960 – 100% of unearned credit
  • Family collection is double up to certain limits –
    • A family of three up to $78,120, capped at double
    • A family of four up to $94,200, capped at double
    • Thereafter – 100% of unearned credit
potential discrimination testing regulations not until after election if at all
Potential discrimination testing regulations – not until after election if at all
  • Highly compensated employees (HCEs)
  • Formerly exclusively tested for health insurance issues in self-funded plans
  • IRS code Section 105h mandated that employers could not have a plan for HCEs with higher level of benefits (no deductible or copayments, 100% coverage, etc.) or a plan with employee contributions that were different from non-HCEs
  • Likely to be left as “still working on it”
waiting periods for new hires
Waiting Periods for New Hires
  • SB 1034 Senate Bill Monning and CAHU
  • Signed August 14, 2014
  • 90 day period in California starts 1/1/2015
  • Federal ACA IRS
    • Allows firms with “bona fide orientation period that occurs before the 90 waiting period begins”
    • Up to an additional month
    • Subject to audit that the orientation was not designed to avoid compliance with the 90 day rule
why brokers belong in the system
Why Brokers Belong In The System
  • Self interest promotes honest brokerage
  • Brokers are used for data gathering and self interest promotes the proper application of rules.
  • Fact checking for accuracy and completeness is done usually with a higher level of intensity.
  • Analysis of data gathered is compared against the rules to determine the likely judgment of the final premium rate.
handling employer group issues and strategies
Handling employer group issues and strategies

Consumer directed

HMO, PPO, EPO and the Alphabet Soup

Carve Outs - Management Groups, Clerical Groups or Union Groups

ERISA/PPACA guidance

Legal Dangers

Human Resource Regulatons

Self-fund, partially fund, fully insure or release to the exchange

How to attract and keep the best employees at the most reasonable cost?

different roles
Different Roles

Service after the sale related to receiving

medical care or claims resolution

Explaining a very difficult

insurance contract

Defender - Advocate


employee’s interest

Educator of change

Protecting employer’s


Cost Management

Helping an employer find ways of providing health care

benefits at work by financing it through insurance


Present renewals with appropriate historical data and options to meet the employer and employee objectives.

  • Provide model notices and assistance with COBRA & ACA.
  • Make sure client is aware of FMLA and ADA responsibilities.
  • Find compliance partners for COBRA, HIPAA, Section 125 and FMLA
  • Design employee contribution strategies.
  • Interact with the insured or employer to help resolve issues with providers, as well as federal and state government.
  • Assist terminated employees with their options.
  • Assist employees with Medicare issues.
  • Integrate with other employee benefits plans.
  • Give advice on all issues surrounding their plan including governmental requirements.
  • Interface actions with exchange options
  • Present wellness initiativesto help improve the health of employees.
  • Assist with employee communications, including printing of material and the running of employees meetings.
  • Assist with the research and resolution of claim conflicts.
  • In addition to making a sale, below is a partial listing of some of the things we do for our clients:
  • Prepare clients now for 2015 reporting
  • Notify individual clients getting premium tax credits to adjust their credits now
  • Alter employer waiting periods to conform to new rules
  • New discrimination rules are on delay
  • Prop 45 – join the fight against it
like we did the day we got into this business
Like we did the day we got into this business.

We’ll adapt

… offer new solutions

… continue the fight

… with your help and