Brokers

How brokers compare group health plans

Census, employer location, filed carriers, and the quoting tools brokers use to compare group plans.

Comparing group health plans is a research job before it is a proposal job. This page is for employee-benefits brokers. It describes the facts that have to be true before a side-by-side means anything. It is not a ranking of carriers or software.

Start with the census

A complete census is the first filter. You need eligible employees, dates of birth, ZIP codes, hours if the plan uses them, current coverage or waiver status, and who will take spouse or child coverage. Ages and dependent mix move small-group rates. Missing dates of birth produce dummy quotes that you will redo.

Ask whether the list is eligible employees or all W-2 names. Carriers rate on eligibles and then apply participation. If the group has COBRA participants, retirees, or owners on a different class of coverage, separate them. Mixing those rows into the eligible census is a common way to get a number that will not bind.

Where the group is based

Carriers file small-group and many large-group products by state, and they rate by area. The employer’s main location and ZIP decide which filed plans you can show. Use the business location, not a producer’s office and not a remote owner’s home state, unless that is truly where the group is based.

Write down every state where employees live and work. A group based in one state with three people in another is a different case from a group whose people are spread across the country. Out-of-area employees affect network access, and they can take a carrier off the list even when the home-state rate looks fine.

You can only compare plans that a carrier has filed where the group is based, at the size band you have, for the funding type the employer will accept. Fully insured small-group, level-funded, and ICHRA are different comparisons.

Check appointment and release status. A rate on a carrier you cannot write is not a quote. Confirm that the writing GA or carrier appointment is active for that state and product line.

Then compare the same things on every option: employee-only and family rates, deductible and out-of-pocket, network name, Rx copays or coinsurance, and what happens to out-of-area people. Keep plan names and metal levels honest. Participation and employer contribution belong on the same grid. A low rate that the group cannot meet is not a win.

Out-of-area employees

Out-of-area people are where quotes go bad after you have already presented. Ask how many eligible people live outside the employer’s home rating area, which network they would actually use, and whether the carrier treats those ZIPs as in-network on this product.

If a meaningful share of the group is out of area, a tight local HMO may be the wrong headline option even when it is the lowest home-state rate. A broader PPO may be the plan people can use. Put that in the proposal in plain language.

For groups that are truly scattered, a group plan may not be the better fit. ICHRA vs group medical covers when an allowance plus individual coverage is the more ordinary path.

Quoting and proposal tools

Most shops do not key every rate by hand. Zywave is the quoting and proposal tool already listed in this directory. Benefits CPQ (also marketed as CPQ: Employee Benefits) is the Zywave product that rates medical and ancillary plans and builds branded proposals. Use it — or the rater you already run — as a workspace, not as a verdict. Confirm anything you will present against the carrier or GA exhibit.

After the employer picks a plan, enrollment still has to run. Employee Navigator is the enrollment and benefits-administration platform already listed here. A quote that cannot be enrolled cleanly — missing 834, no new-hire path, no ACA reporting if the group needs it — is an unfinished compare.

A practical order of work

Confirm eligible headcount, hours rule, and where the group is based.
Collect a current census and a list of states where people live.
Decide which funding types you are actually comparing.
Rate only filed, writable carriers for that state and size.
Call out out-of-area network gaps before you present.
Put participation, contribution, and enrollment ops on the same page as the rates.

Shop the market that way every time. The software does not replace the judgment about who can actually use the plan.

Innov8 Tools is a free directory published by Innov8 Healthcare. Brokers can use these pages as a consistent fact set. It is not a ranking and not a paid placement list.