Filed Under:Health Insurance, Individual Health

After PPACA: The Future of the Health Insurance Underwriter

Because current health care reform legislation limits the use of health status in underwriting and restricts actuarial pricing by age and sex, you may think that soon, there will no longer be a need for those pesky health insurance underwriters - you know, the humans you never see but who you swear are holding up your submission and catching the slightest of irrelevant missing information?

But before you get ahead of yourself, let's review the functions of underwriting. Underwriters...

  • Oversee the process of issuing insurance policies
  • Manage the process that any large financial service provider (e.g., an insurer ) uses to assess whether a customer is eligible to receive its products
  • Evaluate and measure risks and exposures of potential clients
  • Determine the premium that needs to be charged to insure that risk

With those points in mind, even with PPACA, underwriting still has its purpose. The criteria for individual and small-group underwriting (excluding grandfathered plans) that's effective 2014 will change, however, and focus on only four areas

This aspect of reform mandates that employers up to 100 employees are considered to be in the small-group market, although states can opt to maintain their small-group markets with fewer than 50 employees in 2014 and 2015.

How is this different from what we have today?

  • Health status, gender, and participation requirements will no longer be underwriting factors - not to mention that the prescribed ratios above are now uniformly mandated and regulated across the country for each carrier, in order to level the playing field.
  • Including grandfathered plans, the medical loss ratio requirements (MLR) dictate that carriers must spend 80 percent of the individual and small-group markets' (under 100) and 85 percent of the large-group market's (100+) total revenue on claims, after factoring in risk adjustment, reinsurance, and risk corridor payments. The exceptions: HHS can make adjustments for states proving that requirements of 80 percent or higher could destabilize it. This doesn't address the group market, however.

So what does this mean for underwriting departments and agents?

Essentially, it means that underwriters and actuaries will soon serve an even more important role, seeing as how carrier rates must be more precise to ensure that the insurance companies can operate in accordance with the guidelines, which, in effect, restrict premium. The restricted rating factors above, coupled with increased claims dollars paid out and increasing benefit consumption, equal a financial challenge of epic proportions.

In other words, we need sharp actuaries to accurately set base rates, underwriters to appropriately assess risk, and consumers to judiciously use insurance in order for this thing to work. Agents should be in employer break rooms, warehouses, and conference rooms across America, educating consumers. Use this to your advantage to shape the landscape by changing the ways that consumers view health insurance.

Underwriters and actuaries are entering into unchartered territory, along with the rest of us. Be nice to them.

And as a bonus, here are tips for your new submissions to underwriting, which are guaranteed to improve turnaround time:

  • Complete, legible, adverse groups shouldn't be sent to just one carrier
  • Be nice, accurate, precise, and prompt

Gentrie Pool is the Texas sales company representative for U.S. Health and Life Insurance and current president of the Fort Worth Association of Health Underwriters. She can be reached at or 817-454-9304.

Featured Video

Most Recent Videos

Behind the scenes with Vicki Gunvalson [VIDEO]


In this exclusive interview, Vicki Gunvalson shares how she built a $15 million a year annuity business by planning for...

Regulator: Market may need to reinvent LTCI


Cioppa says Maine's governor wants to spur the creation of better products.

Dementia: It's more than Alzheimer's


An association calls for policymakers to remember lesser-known neurodegenerative conditions.

Protesters Disrupt WellPoint Annual Meeting


Hecklers call for more disclosures of information about political contributions.

Related resources

More Resources


Power your business with up-to-the-minute insurance news, analysis, and best practices from LifeHealthPro Daily eNewsletter – FREE.

Power your business with LifeHealthPro Daily eNewsletter – FREE.

Enter a valid email address.
Nichole Morford

Nichole Morford
Managing Editor

Thank you for subscribing to LifeHealthPro Daily!

Check Out More eNewsletters Now! Close

Advertisement. Closing in 15 seconds.