Objective 2 - Claim Costs

Question 1

Steps of the Product Development Cycle

Answer 1

Product Development is the process by which new products are created and existing products evolve

1. Innovate - Consists of
   a) Understanding the company’s strategic perspective
   b) Idea generation (see separate list of common drivers of product ideas)
   c) Market Assessment - to determine if a market exists for the product
2. Design the Product - This phase consists of determining the product structure, plan design options, contribution requirements, and regulatory compliance
3. Build the Product - (see separate list of steps for building the product)
4. Sell the Product - The product is often test marketed, after which revisions are done before it is mass marketed
5. Assess the Product - Monitor financial results and consumer and market feedback
6. Revise the Product - Changes may be indicated by the product assessment, regulatory requirements, or consumer demand

Skwire, Chapter 3, Page 27

Question 2

Common Drivers of Product Ideas

Answer 2

1. Innovator or Follower - some companies are successful at innovating, while others are successful at following and learning from competitors
2. Changing laws and regulations - new rules can lead to new products deeloped specifically to operate within the new set of rules
3. Consumer Demand - Companies must constantly seek consumer feedback and market intelligence
4. Marketing and Sales - these teams can spot holes in the product spectrum where demand is not being fully met
5. Leveraging insurer capabilities - product development teams must known what the insurer does well and find ways to grow in those areas
6. Social Need - for example, Medicare Part D served the social need of helping seniors who were being overwhelmed by the cost of expensive medications
7. Changing demographics - leads to a shift in the types of products that will be marketable and saleable
8. Changing economy and financial markets - leads to changes in purchases’ views of their need for insurance
9. Competitive Advantage - Product development ideas should utilize the company’s competitive advantages

Skwire, Chapter 3, Page 29

Question 3

Questions Answered by a Market Assessment

Answer 3

1. (exists) What exists in the Market Today?
2. (Objective) What is the Product Objective for the consumer?
3. (Regs) What is the regulatory environment for this product?
4. (Fin Value) What are the financial value and other benefits for the consumer?
5. (Price Targets) What are the Price Targets? (assessment may indicate a range of acceptable prices)
6. (Competitors) What is the likely reaction from competitors?
7. (Sales Team) How will the sales team react?

Mnemonic - SCORE Final Prices (SCORE F P)

Skwire, Chapter 3, Page 31

Question 4

Steps for Building a New Product

Answer 4

1. (E) Project Enrollment - This is critical to helping senior management decide whether the product is worth pursuing
2. (P) Price the Product - Includes an assessment of the market price sensitivity. After initial pricing, the projected enrollment should be reviewed again.
3. (A) Perform Financial Assessments - to determine whether the new product can meet the company’s required return on investment or return on equity
4. (I) Implement the infrastructure needed to administer the product (process claims, bill and collect premiums, and service member inquiries)
5. (A) Get Senior Management Approval

Mnemonic - Every Product - Assess, Implement, Approve

Skwire, Chapter 3, Page 33

Question 5

Key Players in the Product Development Cycle

Answer 5

1. (P) Product Dev Team - Responsible for generating new product ideas and studying the Market
2. (M) Senior Management - Sets company goals and responsible for making the decision to pursue a proposed idea
3. (M) Marketing - Focused on Advertising, name recognition, and branding
4. (S) Sales - Often has insights into price sensitivity and the types of products customers want
5. (U) Underwriting - Can help quantify the risk associated with certain plan features
6. (I) Information Technology - IT can help in understanding the feasibility of the infrastructure needed to administer the product
7. (O) Operations - Work with IT teams to administer the product
8. (C) Compliance - ensures the product is compliant with laws and regulations
9. (A) Actuarial - Prices the product and works on the projections and feasibility studies
10. Finance - Reviews the projected enrollment and pricing targets to determine whether projections meet corporate profit targets

Mnemonic - OPIUM SCAM + Finance

Skwire, Chapter 3, Page 35

Question 6

Components of Gross Premiums

Answer 6

1. Claim Costs
2. Administrative Expenses - Includes the cost of designing, developing, underwriting, and administering the product, as well as an allocation of overhead costs. Frequently much higher in the first year than in renewal years.
3. Commissions and other sales expenses - Includes special bonuses, incentives, and advertising. Generally expressed as a % of premium.
4. Premium Taxes
5. Other taxes and assessments - Includes federal and state income taxes and new assessments due to the ACA
6. Risk and Profit Charges - depends on the degree of risk involved, the amount of capital allocated to support the product, and the expected return on the capital
7. Investment Earnings - Typically credited based on assets held

Skwire, Chapter 20, Page 325

Question 7

Considerations in developing administrative expense assumptions

Answer 7

1. How expenses are allocated to the product - allocation methods include:
   a) Activity based allocation - distributes expenses according to some measure of use (e.g., actual postage expenses can be charged to the function that generated the mail)
   b) Functional expense allocation - determines how expenses are split by line of business for new and renewal business (done by surveying employees to determine how time is spent)
   c) Multiple Allocation Methods - a combination of the other two methods
2. How administrative expenses should be allocated to groups - should differentiate between first year and renewal expenses. Various allocation bases exist (see separate list)
3. What the competition includes as expenses in its pricing - adjustments may be needed to match what others are doing in the marketplace

Skwire, Chapter 20, Page 326

Question 8

Types of Bases used for allocating expenses

Answer 8

1. Percent of Premium
2. Percent of Claims
3. Per policy
4. Per Employee (certificate)
5. Per Member (Each person covered)
6. Per Claim administered
7. Per Case (some expenses are charged directly to the case for very demanding groups)

Skwire, Chapter 20, Page 327

Question 9

Common Rating Characteristics included in Manual Rates for Group Health Insurance

Answer 9

1. Age
2. Gender
3. Health Status
4. Rating Tiers (Separate List)
5. Geographic Factors
6. Industry Codes
7. Group Size
8. Length of the Premium Period

Skwire, Chapter 20, Page 332

Question 10

Common Rating Tiers for Group Health Insurance

Answer 10

1. One Tier: Composite
2. Two Tier: Employee only, Family
3. Three Tier: Employee only, EE and one Dep, Family
4. Four Tier: Employee only, EE and one Dep, EE with Children, Family
5. Five Tier: Employee only, Couple, EE and Child, EE with Children, Family

Skwire, Chapter 20, Page 333

Question 11

Group Health Claim Costs: Sources of Internal Data

Answer 11

1. Medical Claims Systems Data - Includes billed claims, eligible claims, allowed amounts, and paid amounts
2. Pharmacy benefit manager (PBM) data - organizations that use third-party PBMs to administer the prescription drug claims will need to collect this data from them
3. Premium billing and eligibility data - includes exposure information that is needed to convert claims data into a per member or employee basis
4. Provider contract system data - includes files of contractual reimbursement rates

Skwire, Chapter 21, Page 340

Question 12

Group Health Claim Costs: Steps in developing claim costs for use in a rate manual

Answer 12

1. Collect Data - Data should be collected for an incurral period of at least 12 months (to avoid seasonality issues). The best source of data is a company’s own experience
2. Normalize the data for important rating variables (see separate list)
3. Project experience period costs to the rating period - the trend rate should reflect changes in utilization of services, changes in the average cost services, and other factors, such as regulatory impacts and cost shifting among payers

Skwire, Chapter 21, Page 341

Question 13

Group Health Claim Costs: Important Variables when normalizing data for use in the rate manual

Answer 13

Note: Many of these variables can now only be used in rating large group due to the ACA

1. [A]ge and gender - It may be appropriate to have separate age and gender factors for different major service categories or different plan types (such as high deductible plans)
2. [G]eographic Area - The data should be adjusted to reflect one specific geographic area
3. [B]enefit plan - Adjust the data to reflect a common benefit plan (commonly the richest plan)
4. Group [c]haracteristics - the manual rate should represent the average group with respect to group characteristics, such as industry and group size
5. [U]tilization management programs - adjust for any changes in these programs
6. Provider [r]eimbursement arrangements - adjust the experience to reflect a common reimbursement level
7. [O]ther risk adjusters (based primarily on claim, diagnosis, encounter, and pharmacy data) - these may eventually become the primary method of risk adjustment

Mnemonic - U GRAB O C (U GRAB Overall Characteristics)

Skwire, Chapter 21, Page 343

Question 14

Group Health Claim Costs: Methods of Adjusting Manual Rates for specific benefit plans

Answer 14

1. Claim Probability Distributions - These are typically used to estimate the impact on claim costs of deductibles, coinsurance, and out-of-pocket maximums
2. Actuarial Cost Models - These models build estimated total claim costs by developing a net claim cost (after member cost sharing) for each detailed type of service and summing to get the total

Skwire, Chapter 21, Page 350

Question 15

Dental Claim Costs: Data Sources

Answer 15

1. (Own) Company Data (Best Source)
2. Outside (Data)bases - Prevailing Health Care Charges System, MDR Payment System, National Dental Advisory Service, ADA “Survey of Dental Fees”
3. (C)onsulting Firms (have manuals containing utilization data)
4. Rate (F)ilings of Other Carriers
5. (T)hird Party Administrators (TPA)
6. (R)einsurers

Mnemonic - Own Company’s Data - Fuck The Rest

Skwire, Chapter 22, Page 368

Question 16

Dental Claim Costs: Impact of Plan Characteristics

Answer 16

1. Covered Benefits - Plans often have a missing tooth provision and limit the replacement of dentures to once every 5-7 years
2. Cost Sharing Provisions - These provisions are important because receiving proper dental care is very elective from the insured’s point of view. Provisions include deductibles, coinsurance and copays, and maximum limits.
3. Waiting Period - Used to discourage individuals from enrolling for one year to treat significant dental problems and then dropping coverage
4. Period of coverage - Will need to project past experience onto the future. Dental trend should not be assumed to be the same as medical trend.

Mnemonic - Big Crowns Warp Prices
Benefits, Cost, Waiting, Period

Skwire, Chapter 22, Page 369

Question 17

Dental Claim Costs: Network and Care Management Practices that Impact Dental Claim Costs

Answer 17

1. Provider Reimbursement levels
   a) FFS Reimbursement may be based on usual, customary, and reasonable levels (UCR)
   b) PPO Networks contract for reduced fees from a limited number of dentists. The dentist may not bill above those levels.
   c) Capitation is common with dental HMO plans
2. Care Management Practices - These will depend on the reimbursement method used. Practices include pre-authorization and self-management (for capitated providers.)

Skwire, Chapter 22, Page 373

Question 18

Dental Claim Costs: Insured Characteristics that Impact

Answer 18

1. Age and Gender - Adults have higher costs than children, females have higher costs than males
2. Geographic Area - Can be a significant factor
3. Group Size - Smaller groups have higher costs (due to adverse selection)
4. Prior coverage and pre-announcement - groups without prior coverage will have costs in the first year due to utilization by those who had put off having dental work done. If the plan is announced many months prior to becoming effective, this problem becomes worse
5. Employee Turnover - High turnover increases costs since some new employees didn’t have prior coverage
6. Occupation or Income - entertainers, professionals, and groups who are more aware of their benefits have higher costs
7. Contribution and Participation - Groups with less than 100% participation will have higher costs due to antiselection. The level of participation is inversely related to the required contribution level.

Skwire, Chapter 22, Page 378

Question 19

Pharmacy Claim Costs: Data Fields Included

Answer 19

These files include on record per prescription, and the following information on each record

1. Age, gender, and date of birth of the patient
2. Fill Date - This is the incurred date for the claim
3. Claim ID
4. Prescribing provider ID
5. Pharmacy provider ID
6. Drug name - use of consistent source so the data does not have two different names for the same drug
7. Tier - Category of the drug, as defined by plan design
8. National Drug Code (NDC) - an eleven-digit code used to identify a specific form of a drug. A mapping of NDCs to drug names can be obtained from data vendors
9. Days Supply - scripts are generally grouped into 30-day, 60-day, or 90-day categories
10. Units - the number of pills or a measurement of volume for liquid medications
11. Allowed Amount - Sum of disconnected ingredient cost, dispensing fee, vaccine fee, and sales tax
12. Refill indicators - for prescriptions that allow refills, this shows which fill the current claim is for
13. Member and Plan cost - these fields show how much of the allowed cost is paid by each party
14. Therapeutic class - categorization based on the conditions that the drugs are intended to treat
15. Other types of drug codes - RxNorm Concept Unique Identifier (RxCUI) and Generic Product Identifier (GPI)
16. Average wholesale price and wholesale acquisition cost (AWP and WAC)

Skwire, Chapter 23, Page 388

Question 20

Pharmacy Claim Costs: Steps for Calculating Premiums for Pharmacy Benefits

Answer 20

1. Develop an allowed cost trend, which includes:
   a) Unit Cost Change
   b) Utilization Change
   c) Mix Change - such as a shift between generics and brand name drugs
2. Calculate adjustment factors for important rating variables (see separate list) - factors that are already accounted for in allowed cost trend should not be included as a separate rating factor adjustment, in order to avoid double counting
3. Estimate member cost sharing based on the projected allowed cost - if the plan design uses copays, use the average effective copay, rather than the nominal copay stated in the plan design
4. Calculate net plan liability and premium
   a) Projected allowed amount = base period allowed amount * trend factor * other adjustment factors
   b) Net plan liability = projected allowed amount - member cost sharing - rebates
   c) Premium = net plan liability + expenses + profit margin

Skwire, Chapter 23, Page 392

Question 21

Pharmacy Claim Costs: Important Rating Factors

Answer 21

1. [D]emographics - such as age and gender
2. [A]rea
3. [B]enefit Design - changes in benefits may cause changes in drug use. This is referred to as induced utilization
4. [F]ormulary - costs are impacted by
   a) the list of covered drugs and tier placement of drugs
   b) Formulary management programs, such as prior authorization, step therapy, and quantity limits
   c) brand patent expirations
5. [C]ontracting - PBMs negotiate with pharmacies regarding dispensing fees and discounts off the average wholesale price
6. [O]ther factors - these include changes in mail order utilization, changes in the generic dispensing rate, and changes in utilization management or cost management programs

Mnemonic - BAD F CO (BAD For COsts - if they go up)

Skwire, Chapter 23, Page 393

Question 22

Group Life Claim Costs: Considerations in Developing a Manual Table

Answer 22

1. Two approaches can be used:
   a) Manual Premium Tables - Calculate the manual premium rate, then adjust for group size. This adjustment will reflect the margin, profit, and expenses appropriate for the group size, relative to the averages built into the table.
   b) Manual Claim Tables - calculate the manual claim rates, then add the appropriate margin, profit, and expenses
2. Data Sources - Could use SOA studies, industry mortality tables, population statistics, or own company experience (best source if credible)
3. Change in Mortality - Expected future mortality improvement should be reflected
4. Reinsurance - the net cost of reinsurance should be factored into the claim table or expenses
5. Conversions to individual life policies - these create severe antiselection, which should be reflected in the manual rates
6. Manual adjustments are made for group-specific traits (see separate list)
7. Rates for the group are based on age and gender mix, but groups typically end up charging a composite rate to all employees

Mnemonic - Two Data Monkeys Really Can’t Manually Rate

Skwire, Chapter 24, Page 404

Question 23

Group Life Claim Costs: Use of general population data for pricing life insurance

Answer 23

1. Estimated annual improvements in mortality
2. Determining ratios of mortality by age bucket
3. Comparing male/female mortality
4. Developing rates for very young and very old (non-working population)

Skwire, Chapter 24, Page 409

Question 24

Group Life Claim Costs: Manual Claim Table Adjustments

Answer 24

(could also be referred to as group rating characteristics for life insurance)

1. [D]isability Factors - an adjustment is needed if a group has a different waiver of premium approach than is assumed in the manual rates
2. [E]ffective Date Adjustment - Needed if central date of coverage is not July 1
3. [I]ndustry Factors - based on industry codes such as SIC codes
4. [R]egional factors
5. [L]ifestyle factors - e.g. adjustments based on the % of employees that smoke
6. [M]arketing considerations - e.g., added charges for rate guarantees.
7. [C]ontribution schedules - e.g., 5% discount if the employer pays the entire premium (reducing antiselection)
8. Case [s]ize factors and volume adjustment - larger groups may have lower mortality or expenses
9. Plan [o]ptions - optional benefits and allowing lots of employee choice will create antiselection

Mnemonic - L MC RISE O D (Life Manual Claims RISE Or Decline)

Skwire, Chapter 24, Page 412

Question 25

Group Life Claim Costs: Types of living benefits for Life Insurance

Answer 25

This benefit (also called an accelerated death benefit) pays a portion of the face amount prior to death, with the remaining paid at death

1. LTC Benefits - provides a monthly benefit of 2% of the face amount, beginning when the insured is permanently confined to a nursing home
2. Critical Illness benefits - typically pays 25% of the face amount upon occurrence of a listed disease, such as stroke or cancer
3. Terminal Illness benefit - pays 25% to 50% of the face amount when the insured has been diagnosed with a terminal illness with less than 6 or 12 months to live

Mnemonic - Living: LTC -> LTC (2%), Terminal (25-50%), Critical (25%)

Skwire, Chapter 24, Page 418

Question 26

Disability Claim Costs: Data Sources

Answer 26

1. A company’s own Data is the best source if it is reliable and credible
2. Rate filings of competitors
3. Research of governmental and business publications
4. Data from consulting firms and reinsurers
5. Insurer studies - such as loss ratio studies and actual to expected incidence or termination rates
6. Industry data and tables (typically based on inter-company experience studies)
   a) 1987 Commissioners Group Disability Table - adopted by NAIC as the statutory minimum reserve basis for LTD. is still the most recent incidence rate study.
   b) SOA 2008 GLTD Experience Table - provides considerable detail on claim termination rates
   c) 2012 GLTD Valuation Table - will be replacing the 1987 CGDT for use in developing minimum statutory reserves
   d) TSA reports - contain exposure and actual to tabular ratios by industry classification
   e) 1985 Commissioners Individual Disability Table A (CIDA) - the basis of active life and claim reserves for individual policies
   f) SOA Individual Disability Experience Committee 1990-2006 study

Mnemonic - Own Company’s Data, Fuck the Rest (and Databases)

Skwire, Chapter 25, Pages 419 and 432

Question 27

Disability Claim Costs: Types of Disability Income Experience Studies

Answer 27

1. Calendar Year Loss Ratio Study
   a) Compute the ratio of incurred claims to earned premium for a given calendar year
   b) Incurred claims are calculated as paid claims plus the increase in claim reserves
   c) May not provide a clear picture of historical trends because results are affected by reserve changes
2. Incurral year loss ratio study
   a) Compute the ratio of incurred claims to earned premium for a given incurral year
   b) Incurred claims are calculated as the present value of claim payments made to date plus the present value of the current claim reserve
   c) Shows historical trends because the full cost of a claim is attributed to the year the claim was incurred
3. Study of actual-to-expected incidence or termination rates - ratios of a company’s actual claim incidence or termination rates compared to expected rates from published industry tables or company data

Skwire, Chapter 25, Page 420

Question 28

Disability Claim Costs: Formula for Disability Income Net Monthly Premium

Answer 28

1. Net monthly premium = Incidence Rate * Sum (Benefit-t * Continuance-t * InterestDiscount-t)
2. The summation runs for the entire length of the benefit period
   (offsets will also need to be reflected, which is discussed in a list from GHC-101-13)

Skwire, Chapter 25, Page 422

Question 29

Disability Claim Costs: Group Characteristics that Impact Claims Costs

Answer 29

1. Age and gender
2. Occupation - may need to adjust claim costs for:
   a) Hourly vs. Salaried
   b) Blue collar vs grey collar vs white collar
   c) Union vs non-union
   d) Commissioned sales personnel
3. Industry - For group insurance, it is more appropriate to rate based on industry than on occupations
4. Average earnings per employee - claim rates decrease as average earnings increases
5. Area - claim costs vary due to the legal environment and the general attitude and culture of the area
6. Size of Group - claim costs follow a “U” shaped curve, with higher costs for the largest and smallest employers

Skwire, Chapter 25, Page 428

Question 30

LTC Claim Costs: Major effects of changes in the NAIC LTC Insurance model Act in 2000

Answer 30

1. Requires (disclosure) of rating practices at the time of application - e.g., including a statement that the policy may be subject to the future rate increases
2. Requires an (actuarial certification) at the time of initial rating - must include a statement that the initial rates are sufficient to cover anticipated costs under moderately adverse experience
3. (Eliminates) minimum loss ratio requirements in the initial rate filing
4. Places (limits) on expense allowances in the event of a rate increase. If a rate increase is requested, the lifetime loss ratio must be less than a weighted average of 58% of the initial premium and 85% of the premium increase
5. Requires (reimbursement) of unnecessary rate increases - this could result if the revised premium schedules are more than double the initial rates
6. For policies in a rate spiral, guarantees policyholders the right to (switch) to currently-sold insurance without underwriting
7. Authorizes the commissioner to (ban) companies for 5 years if they persist in filing inadequate initial premiums

Mnemonic - Disclose and Eliminate Actuarial Reimbursement Limits by Banning Switches

Skwire, Chapter 26, Page 437

Question 31

LTC Claim Costs: Major Effects of HIPAA on LTC

Answer 31

1. Defined qualified plans
2. Clarified taxation of premium and benefits - established that a qualified LTC insurance contract shall be treated as an accident and health insurance contract for tax purposes
3. Standardized benefit triggers (see separate list from Leida Ch. 2)
4. Allowed tax reserves to be calculated on a one-year preliminary term basis for tax-qualified plans

Skwire, Chapter 26, Page 441

Question 32

LTC Claim Costs: Major Stakeolders in Policy Design Process

Answer 32

1. Employer Group
   a) LTC is appealing because it complements other products (such as disability and life coverage) and relative to medical is a low-cost benefit with stable pricing
   b) May not be able to offer guaranteed issue to all active employees, since this could make the premiums more expensive than similar individual policies
2. Insurance Company
   a) Concerned with up-front acquisition costs, the risk of low enrollment, and the need to sell to both the employer and employee
   b) Costs vary significantly by participation level, making this a key assumption
3. Employees
   a) May not yet be aware of the risk covered by LTC insurance
   b) Concerned with the significant cost, which may even exceed the cost of individual policies
4. Insurance brokers - have found that group LTC insurance provides the opportunity to open the door to competitive life and disability markets

Skwire, Chapter 26, Page 443

Question 33

LTC Claim Costs: Assumptions needed for an LTC Pricing Model

Answer 33

1. (Voluntary) Lapses - Lapse rates are much lower than for other types of health insurance. Premiums are very sensitive to changes in lapse assumptions, especially for products with inflation protection
2. (Mortality) - Most companies use the 1994 Group Annuitant Mortality Table
3. (Morbidity) - Major variables that impact claims costs are:
   a) Marital Status - costs are lower for married individuals because of the presence of a potential caregiver at home
   b) Gender - Females have significantly higher ultimate costs than males
   c) Benefit Trigger
   d) Area - Utilization patterns of LTC services vary by geographic area
   e) Case Management - companies using a case manager usually experience lower claims
4. (Selection) factors - to reflect underwriting wear-off. Depends on the level of underwriting performed
5. (Expenses) - start-up expenses are high relative to other types of business
6. (Interest) - the investment rate on assets is a key assumption because o fthe large amount of reserves
7. (Reserve) Basis - important considerations include the level of margins and how these margins are achieved
8. (Other) assumptions - Including the average daily benefit and the premium mode
9. (Profit) - Typically based on lifetime goals for pre-tax profits, post-tax profits, return on investments, or return on equity

Mnemonic - Voluntary Mortality PROMISE

Skwire, Chapter 26, Page 448

Question 34

Components of Medical Trend

Answer 34

The component method for developing pricing trends combines the following to get the pricing trend

1. Core Cost Trend - the rate of increase in the covered cost per service, before adjusting for specific factors such as aging or one-time changes. 3 Parts:
   a) Unit Cost Trend - Change in payments to providers for a fixed basket of services
   b) Severity - Increase in the intensity of treatment
   c) Change in mix of services - such as changes in the distribution of type of service or provider
2. Core Utilization Trend - Includes changes in utilization due to external forces, such as the economy, the number of workdays during the period, and changes in medical practice
3. One-time Changes - a response to a specific, identifiable situation. Types include:
   a) A significant change during one period, followed by a return to normal the following period. I.e. Severe flu season or weather events
   b) A sustained change in claims level. Examples include legislative changes (new mandated benefits) and internal changes
4. Expected Population shifts - includes changes in geographic mix and age-gender mix
5. Structural changes - includes leveraging, benefit changes, changes to clinical programs, and network changes
6. Capitation - can impact trends if there is a material changes in the average capitation fee of bonus payments
7. Margin - added to best estimate trend to minimize change of a loss

Skwire, Chapter 34, Page 599

Question 35

Key Questions to ask when analyzing trends

Answer 35

1. How (accurate) were the original projected trend and PMPM estimates
2. Which assumptions were (driving) any variation?
3. How can the process be (modified) to achieve greater accuracy
4. What other (factors), expected or unexpected, drove trends

Mnemonic: Accuracy Drives Improved Factors

Skwire, Chapter 34, Page 606

Question 36

Factors that may influence future trends

Answer 36

1. The Impact of Exchanges - enrollees will likely change health plans more frequently than in the past, which will require insurers to have a more in-depth understanding of the impact of population shift
2. Cost savings initiatives - includes accountable care organizations (ACOs), clinical interventions, and wellness programs
3. The economy - some economic factors may help in setting better trend estimates

Skwire, Chapter 34, Page 610

Question 37

Desired Characteristics of Premium Rates

Answer 37

1. Adequate - High enough to generate an acceptable return on equity
2. Competitive - low enough to enroll enough members to meet volume and growth targets
3. Equitable - to avoid an unreasonable amount of cross-subsidization among groups (which will improve persistency)

Mnemonic - ACE!!! those premiums

Kongstvedt, Chapter 22, page 473

Question 38

Information Gathered During Underwriting for Managed Health Care

Answer 38

1. Health Status - Determined based on:
   a) For individual and small group - Physician exams, prescription drug history, and medical questionnaires
   b) For large groups - medical cost experience and a listing of employees’ major health conditions
2. Ability to pay the premium - based on income verification and credit history
3. Availability of other coverage - information is needed for coordination of benefits with other insurance and workers’ compensation
4. Historical persistency - groups that frequently change carriers may not persist long enough for insurer to recoup acquisition costs

Kongstvedt, Chapter 22, Page 474

Question 39

Steps in the Rate Formula for Managed Health Care

Answer 39

1. Develop the projection period base rate PMPM - based on historical medical cost trended forward, and reflects the average characteristics of the block of business
2. Apply group-specific additive adjustments - such as the added cost of covering mandated services in a given state
3. Apply group-specific multiplicative adjustments - includes factors for the benefit plan, geographical area, age/gender, degree of health care management, and health status
4. Add retention loads - includes administrative expenses, a buildup of contingency reserves, coordination of benefits savings, and profit
5. Convert to a contract rate (per EE or per subscriber) - for group coverages, this includes developing tiered rates (employee only, family, etc)

( Projection Base PMPM + Additive Adjustments ) x Multiplicative Adjustments + Retention -> Contract Rate

Kongstvedt, Chapter 22, Page 479

Question 40

Common Purposes for Trend Analysis

Answer 40

1. Financial Reporting - Should meet the following criteria:
   a) Be done on a retrospective basis
   b) Be done at the enterprise level, as well as the division or market level
   c) For statutory reporting, include a provision for adverse deviation. But for GAAP reporting, be on a best-estimate basis
2. Pricing - For setting premiums or for planning and budgeting. Trend rates may be calculated on the following bases:
   a) Eligible charges (billed charges before provider contracts or discounts are applied)
   b) Covered charges (allowed charges)
   c) Net paid claims - shows the bottom line trend after accounting for changes in provider contracts, member cost sharing, and coordination of benefits
3. Experience Analysis - for analyzing changes in a block of business over time

Skwire, Chapter 34, Page 595

Question 41

Rate Setting Approaches

Answer 41

1. Re-rating - rating based on direct, existing experience (e.g. the experience of an existing block)
2. Fundamental Pricing - rating from other data sources (used as benchmarks), which adjusted to apply to the current situation
   a) Tabular Method - an existing table (or a modification of it) is used as the morbidity basis for pricing (e.g. the 1985 CIDA table for pricing DI). Typically used for long-term, non-inflationary-sensitive products.
   b) Buildup and density functions (see separate list) - a model is built to determine expected claims in the rating period. Generally used for inflation-sensitive products.
   c) Simulation - an existing distribution of expected claims is projected into the rating period, using all known information about the claimants (including prior claim experience)

Leida, Chapter 5, Page 161

Question 42

Major Considerations in the Rate Setting Process

Answer 42

1. The Market - competitors’ pricing sets expectations for consumers, limited pricing options
2. Existing products - expectations will be based on the pricing strategies used for the current products.
3. Distribution System - the compensations system, the structure of the distribution system, and the level of company control are all relevant in pricing.
4. Regulatory Situation - limitations may exist that impact how rates are set, and whether needed rate increases are allowed
5. Strategic plan and profit goals - pricing practices should reflect the company’s goals

Mnemonic - MED-RS (Medical Risk Scores)

Leida, Chapter 5, Page 161

Question 43

Major Rating Variables for Health Insurance (Individual)

Answer 43

1. Age - Claim costs increase significantly by age for almost all health insurance coverages
2. Duration - durational trends are the trends in excess of those generated by insured age alone. They typically come from initial underwriting and from cumulative anti-selection.
3. Gender - most coverages vary rates by gender
4. Martial status - this is a big factor for LTC - since having a spouse at home can decrease the need for a nursing home
5. Parental (or family) status - Rates must vary base don how many people are insured
6. Occupation - an important rating factor for DI coverages, but not for other coverages (what about dental?)
7. Geographic area - rates may vary by area due to different patters of care, provider contracts, availability of care, and legal requirements
8. Current Health status
9. Past claim history
10. Smoking status
11. Weight
12. Presence and nature of other coverage
13. Situation specific factors - e.g., whether the policyholder converted from another plan

Leida, Chapter 5, Page 164

Question 44

Types of Age Rating Structures

Answer 44

1. Attained Age Rating - a policyholder’s rate is a function of his or her age at renewal. Also referred to as step rating if rates are grouped into age bands.
2. Entry age or issue age rating - the rate reflects the age of the policyholder when the policy was issued
3. Uni-age rating - the rate structure doesn’t recognize age at all, leading to subsidization of older individuals. Most community rate structures are uni-age.

Leida, Chapter 5, Page 164

Question 45

Tabular Method Formulas for Calculating Net Premium

Answer 45

Tabular method formulas for calculating Net Premiums

1. Net Premium = Sum( Pr (Claim) * Averge Claim Cost * Discount factor * proportion of originally issued lives still in force) over z.
   a) Pr(claim) is the probability of a claim occurring (incidence rate) in year z
   b) AC(z) is the average claim cost (assuming a claim occurs) in year z
   c) v(z) is the discount factor corresponding to year z
   d) l(z) is the proportion of originally issued lives still in force in year z
2. The average claim cost (AC(z) ) is calculated as follows:
   Sum ( clm$ * Pr ( 1 - Tn(s) ) * v(s) over s
   a) s is the claim duration
   b) clm$ is the claim dollars payable at duration s
   c) Pr (1-Tn(s) ) is the probability of a claimant at claim duration 0 remaining disabled at duration s
   d) FnlCmPyt is the claim duration of the final possible claim payment

Leida, Chapter 5, Page 176

Question 46

Using the Buildup and Density function approach for pricing

Answer 46

1. Buildup approach - each claim type (impatient, outpatient, etc.) has its own claim cost calculation, as the product of claim frequency times average cost per service. The total claim cost is the sum of the various categories. Works well for benefits with copays.
2. Density Function - calculates a distribution of the expected annual claims for an individual, with no calculation of the different categories of benefits. Is useful when calculating the impact of deductibles and out-of-pocket limits.
3. Combining buildup and density functions - for PPO products, may calculate in-network costs using a buildup approach (due to copays), and out-of-network costs using the density approach (due to deductibles). The two are combined to get a final claim cost.

Leida, Chpater 5, Page 180

Question 47

Steps of the Rerating approach for Pricing (Individual)

Answer 47

1. Gather Experience on existing Business - use incurred claims (preferably on a runout basis) and earned premiums. The reliability of the data should be assessed before using it.
2. Restate experience - past premiums should be restated to the rate levels currently in effect.
3. Project past results to the future - adjust for items that cause future experience to differ from past experience (see separate list)
4. Compare the projection against desired results - a rate increase is calculated by determining how much rates need to change to produce the desired loss ratio (which is based on the expected level of expenses and profit)
5. Apply regulatory and management adjustments (see separate list for reasons for management adjustments)

Mnemonic - Gather, Restate, Project, Compare, Apply

Leida, Chapter 5, Page 188

Question 48

Adjustments needed for using past claims to project future claims (Individual)

Answer 48

1. Changes in Covered (Populations)
2. Changes in (Duration) - should anticipate durational effects in the claim costs
3. Changes in (Benefits) - changes may be explicit (such as a change in copays) or implicit (such as a change in how a policy provision is interpreted)
4. Changes in claim (Costs) - must project changes in frequencies and changes in average costs, e.g. Trend
5. (Leveraging) - as trends change the average claim cost, the impact of deductibles and copays cause claims to increase at a greater rate than trend
6. (Other) Changes - includes antiselection, changes in underwriting, and changes in business practices

Project claims(t) = Claim Cost PMPM(s)

• # of Members(t)
• (1+leveraged claim cost trend)^(t-s)
• Average Dur Factor(t) / Average Durational Factor(s)
• (1 + Antiselection Factor due to lapses (t-s) )
• (1 + Adjustment factor for other changes (t-s) )

t - Projection period
s - Experience period

Mnemonic - Only Bother with PaiD CLaims (O B PD CL)

Leida, Chapter 5, Page 193

Question 49

Reasons for Management Adjustments in Pricing

Answer 49

1. Competitiveness of the premiums for new business
2. Profitability in other lines of business
3. Relations with the public or the sales force
4. Social Policy
5. Desire to Manage a block from a long-term prospective (e.g. phase in a large rate increase)

Leida, Chapter 5, Page 202

Question 50

Methods for Calculating Gross Premiums

Answer 50

1. Block Rating (Short time horizon) Approach - claim costs are calculated for the rating period (typically a one-year period), and premiums are calculated by adding on the expenses and profit charges. Gross Premium = G = [N * (1 + E^N) + E^F] / (1 - E^G)
   a) N = Net premium (Claim Costs)
   b) E^N = Percent of claim expenses
   c) E^F = fixed expenses
   d) E^G = percent of premium expenses + profit (% of prem)
2. Asset Share Approach - involves long-term projections of various items, in order to determine the necessary premium

Leida, Chapter 5, Page 204

Question 51

Items Included in Asset Share Projections

Answer 51

1. Exposure Values - including the number of policies sold or in force, number of claims or claim payments, number of premium collections, and number of units sold or in force
2. Revenue values - including premium, investment income, and explicit subsidies
3. Claim Values - paid claims, incurred claims, claim reserves, claim adjustment expense reserves, and policy reserves
4. Capital Values - must model the cost of the capital used by the line of business
5. Expense targets - expense loadings may be very detailed. The cost of capital is sometimes treated as an expense.
6. Profit Targets - profit is calculated in one of the following ways:
   a) % of Premium - PV of profits / PV of Premium
   b) Return on Investment (ROI) - Interest rate at which the PV of future profits = initial investment
   c) Return on Equity (ROE) - this is like ROI method, except the initial investment is increased by the amount of capital that is set aside to cover the business

Leida, Chapter 5, Page 207

Question 52

Steps for Manual Rating of Disability Coverage

Answer 52

1. Determine the base rates / premium (Base premium = base rate * benefit amount)
   a) LTD: Base Rate (x,g,e,w) = I(x,g,e) * RSV(x,g,e,0) / 12
   (RSV is the reserve at time 0, I is the probability of claim)
   b) STD: Base rate(x,g,e,w) = I(x,g,e) * D(x,g,e) / 12
   (D is the expected length of claim in weeks)
2. Deduct offset credits - to get to the net base premium
3. Demographic adjustments - adjust the new base premium to reflect the person’s salary, industry, occupation, and location
4. Plan provision adjustments - adjust for the definition of disability, maximum and minimum monthly benefits, pre-existing clause, and antiselection
5. Non-claim adjustments (Retention) - the prior steps give the final claim cost. Add loadings for commissions, expenses, and premium taxes
6. Add profit - can be a % of premium or a needed ROI/ROE

GHC-101-13, Page 17

Question 53

Steps for Experience Rating of Disability Coverage

Answer 53

1. Determine the group’s manual rate with profit and expenses removed (this is the final claim cost)
2. Determine the experience-based rate using the last 3-5 years of data
   a) Discount claims and reserves to the midpoint of the experience period or to the actual date of disability
   b) Divide by exposure to get the experience-based claim rate
   c) if large claims are pooled, add a pooling charge
3. Blend the manual rate and the experience-based rate to get the case claim rate
   a) Blended rate = manual claim rate * (1-Z) + Experience Claim Rate * Z
   b) Credibility (Z) = N / (N + K) Where N = number of life years and K = constant (for example, 5000 for LTD, 250 for STD)
4. Final case premium = blended rate / target loss ratio

GHC-101-13, Page 20

Question 54

Steps in the claim process for disability

Answer 54

1. Determine eligibility for coverage - is the claimant insured and actively at work, is there a pre-existing condition?
2. Determine if the definition of disability is met - this is the most difficult step of the process
3. Determine the payment amount (usually straightforward) = Pre-disability income * benefit percent - offsets
4. Get ongoing proof of disabilities
   a) STD - often approved for a specified period based on the type of disablement. Reviewed at the end of the period
   b) LTD - reviewed annually, when the condition or treatment changes, or when the definition of disability changes

GHC-101-13, Page 31

Question 55

Tools of the claim process for determining and handling disabilities

Answer 55

1. Medical Evaluation - Begins with an APS and can include independent medical exams
2. Rehabilitation plans - providing vocational training or physical rehabilitation
3. Financial Evaluation of the claimant - verification of pre- and post-disability earnings
4. Settlements - These are Risky, so be sure the insurer is not perceived as taking advantage of the claimant (ensure legal representation)
5. Fraud review - check information for inconsistencies or alterations
6. Managed disability - techniques are used to “manage” disability and encourage a return to work

GHC-101-13, Page 33

Question 56

Payment mechanisms for Prescription Drugs

Answer 56

1. Average Manufacturer’s Price (AMP) - the price manufacturers use for selling to wholesalers. In Canada, this is called the manufacturer’s list price (MLP) and is regulated to ensure the prices charged are reasonable and in line with the prices of alternative treatments
2. Wholesale acquisition Cost (WAC) - the manufacturer’s suggest list price, which may also be used as a sale price to the wholesaler
3. Average wholesale price (AWP) - is based on data obtained from manufacturers and distributors, but it’s not an average nor is it based on any actual prices paid by anyone
   a) WAC and AWP are the most widely accepted mechanisms. WAC must = 80% of AWP in the US, due to legislation
4. Actual acquisition Cost (AAC) - The price retailers pay to wholesalers, negotiated between the two parties. In some cases, pharmacies buy directly from manufacturers, in which case AAC = AMP
5. Usual, & Customary (U&C) retail price - the price consumers pay to retailers. It includes the retailer’s AAC plus a markup.
6. Maximum Allowable Cost (MAC) - is typically used for generic drugs and can be viewed as a fee schedule.

GHC-105-14, Page 1

Question 57

Layers (participants) within the prescription drug distribution channel

Answer 57

1. Manufacturers produce drugs and typically sell them to wholesalers based on AMP or WAC
2. Wholesalers act as a middlemen because retailers generally prefer to purchase drugs from one source rather than negotiating with hundreds of individual manufacturers. They sell to retailers based on WAC plus a markup or a discount off AWP
3. Retailers (pharmacies) dispense prescription drugs to consumers, charging a U&C retail price. But if insurance is involved, the retailer will negotiate pricing with the insurer or its contracted pharmacy benefit manager (PBM)
4. Consumers purchase drugs at the U&C price if there is no insurance. If insurance is involved, consumers typically pay a co-payment or coinsurance and the insurer pays the rest of the negotiated price.
5. PBMs and insurers are not involved in distributing drugs except for PBMs who own mail service or specialty pharmacy facilities

GHC-105-14, Page 1

Question 58

Misconceptions regarding LTC Rate Increases

Answer 58

1. Misconception 1: These products are annually renewable
   a) LTC is guaranteed renewable and priced on an issue age basis
   b) Premiums are expected to remain level and cover all future costs
2. Misconception 2: Using historical loss ratios to determine performance is appropriate
   a) Claims and loss ratios are low in early policy years, but this does not mean the product is profitable
   b) A large portion of early premiums need to be set aside as contract reserves to pre-fund future claims
   c) This can be addressed by including the change in contract reserves in the claims calculation
3. Misconception 3: Companies have time to wait and see how experience will unfold
   a) As more time passes without a rate increase, the future premium base to which the rate increase would be applied shrinks
   b) This results in much larger increase needs in order to produce the targeted lifetime loss ratio

Mechanics and Basics of LTC Rate Increases, Page 1

Question 59

LTC pricing assumptions that often drive the need for a rate increaseq

Answer 59

1. Morbidity - misses on this assumption may not become apparent for many years because of the gap between the average issue age and the average age of LTC claimants
2. Persistency - higher persistency leads to significantly higher claims because more policyholders remain in later years when claim costs are extremely high
3. Interest - Investments are key to ensuring that the contract reserves grow enough to support the company’s future liabilities. THe recent economic recession has resulted in investment earnings that are much lower than what was assumed.

Mechanics and Basics of LTC Rate Increases, Page 7

Question 60

ASOP #23 - Actuarial Standards for use of Data

Answer 60

1. Selection of data (See separate list)
2. Reliance on data and other information supplied by others - the actuary may rely on such information, but should disclose this reliance
3. Review of data - the actuary should review the data for reasonableness and consistency, unless such as review is not practical
4. Limitation of the actuary’s responsibility - the actuary is not required to audit the data or determine whether data supplied by others is intentionally misleading
5. Use of Data - the actuary must decide whether the data is of sufficient quality, if adjustments need to be made, or if data defects prevent the analysis from being done
6. Documentation regarding data quality (see separate list)

Selection Reliance Review Limitation Use Documentation

ASOP #23, Page 3

Question 61

ASOP #23 - Considerations in Selection Data for Actuarial Analysis

Answer 61

1. Appropriateness for intended use
2. Reasonableness, comprehensiveness, and consistency of the necessary data elements
3. Any known material limitations of the data
4. The cost and feasibility of obtaining alternative data in a reasonable time frame
5. The cost and benefit associated with using an alternative data set or data source
6. Sampling methods that were used to collect the data

ASOP #23, Page 3

Question 62

ASOP #23 - Required Documentation related to data quality

Answer 62

1. Process the actuary followed to evaluate the data, and any limitations due to data that was not reviewed
2. A description of any material defects the actuary believes are in the data
3. A description of any adjustments or modifications made to the data
4. Source of the data
5. any limitations on the use of the actuarial work product due to data quality issues
6. Any unresolved material concerns the actuary may have about the data
7. Any results that may be biased due to data quality issues, included the magnitude of the bias
8. Disclosures in accordance with ASOP#41 in the following situations:
   a) If any material assumption or method was prescribed by law
   b) If the actuary relies on other sources and thereby disclaims responsibility for any material assumption or method
   c) If the actuary has otherwise deviated materially from ASOP guidance

ASOP #23, Page 6

Question 63

ASOP #25 - Situations in which ASOP #25 applies

Answer 63

1. When the actuary is required by applicable law to evaluate credibility
2. When the actuary chooses to evaluate the credibility of subject experience
3. When the actuary is blending subject experience with other experience
4. When the actuary represents the data being used as statistically or mathematically credible

ASOP #25, page 1

Question 64

ASOP #25 - Recommended practices for using credibility procedures

Answer 64

1. The actuary should use an appropriate credibility procedure when determining if the subject has full credibility or when blending the subject experience with the relevant experience. In selecting a procedure, consider:
   a) Whether the procedure is expected to produce reasonable results
   b) Whether the procedure is appropriate for the intended use and purpose
   c) Whether the procedure is practical to implement when considering its cost and benefit
2. The Actuary should exercise professional judgment in selecting relevant experience to blend with the subject experience. This relevant experience should have characteristics similar to the subject experience.
3. The actuary should use professional judgment when selecting, developing, or using a credibility procedure
4. The actuary should consider the homogeneity of both the subject experience and the relevant experience

ASOP #25, Page 3