So far, says George Pantos, executive director of the Healthcare Performance Management Institute, employers are feeling a lot of uncertainty. Like many parts of health care reform, this provision has been challenged and there is a possibility it could be repealed, come elections next year. Maine has actually been granted a waiver, which postpones the implementation by three years. Other states have followed suit, hoping for the same result.

Pantos says that as the area still evolves, one thing is clear to him: brokers will have to add new value to justify their commissions. Brokers will need to take on a new role: that of the "trusted advisor, to guide clients," says Pantos.

In fact, Pantos and the HPM institute will soon be releasing a white paper focused on re-educating brokers on the challenges of MLR.

However, many brokers say they already provide plenty of value, including after-the-sale service.

 "I really want to drive home … the amount of time and energy that agents and brokers spend servicing the account after the sale," said Beth Ashmore, a health care insurance specialist in Lubbock, Texas and a former president of the National Association of Health Underwriters, in a speech before a panel of insurance commissioners in Austin, Texas.

Speaking in the same panel, Terry Headley, an agency owner in Omaha, Neb., and current president of NAIFA said that the policy sale is "just the beginning" of services brokers provide for clients.

Consulting or service fees have been considered as a way to replace lost income for brokers, but Headley says this adversely affects employees, who will end up having to pay extra fees on top of their premiums. Also, some states prohibit charging a fee when a commission is already made on a sale.

Another concern for employers is making sure that clinically-proven tools and services are included in the clinical services and health care quality categories of expenses under MLR.

If these services don't remain part of, it could drive employers to sponsor self-funded plans, which are exempt from the provision.

Paul Lambert, a partner with 360 Corporate Benefit Advisors in Fairfield, Conn., says he expects more insurers will move to a fee basis for payment. This means that employers will want to know more about where their premium dollars are going.  "[A fee basis] will make it very transparent, and every month they'll see what they're paying the broker," he said, which is likely to lead to lower fees from brokers.

In addition, employers will want to know if their group is benefiting from the MLR requirements or if they are subsidizing other employers.

"If my company's claims are running well, am I subsidizing other groups whose claims are not running as well?" said Joe Torella, president for employee benefits for Hub International Northeast in New York City.

"Exactly what is the cost of claims, how much am I spending administratively, where are those dollars going, and how do I compare to other groups? Insurers will be challenged to provide this data, and it will make self-insured models more appealing to employers," Torella said.

It appears some brokers are already in step with Pantos' recommendations to rethink and adjust to their evolving roles.

Karen Lebeau, benefits specialist for Synergy Services, a Denver-based contingent workforce solutions provider, says that she is seeing brokers trying to increase volume to off-set commission reductions. "They are willing to go the extra mile to get as many clients as possible in order to increase the volume of business," she said. 

Lebeau says brokers are also adding perk services such as including website builds and offering newsletters and email blasts "to enhance the flow of information to the employee," to reduce the time and resources that human resources or benefits managers normally spend doing those things.

She also sees brokers thinking more outside the box "to mold the insurance offerings to the actual needs of the company's culture rather than cookie cutter insurance policies."