MC Chapt 22 Underwriting And Rating Flashcards

1
Q

Community Rating vs experience rating

A
  1. Community rating: experience of a group of indiv is not taken into account, only the collective experience of the risk pool
  2. Experience rating: manual rate is blended with group-specific experience
    1. 1 allowed under ACA for groups with > 100 EEs
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2
Q

Base rate development

Part 1 of 2

A
  1. Historical experience info reflected in base rate
    1. 1 population (e.g. Commercial, Medicare, Medicaid, other)
    2. 2 covered services; cost sharing
    3. 3 provider payment arrangements; demographics
    4. 4 Average members per contract; geographical area
    5. 5 occupation; health status
    6. 6 degree of health care management; coverage effective date
    7. 7 Level of out of network usage, if applicable
    8. 8 presence of workers’ compensation insurance
    9. 9 Underwriting practices; claim admin practices; distribution methods
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3
Q

Base rate development

Part 2 of 2

A
  1. Adjust for changes in health plan operations between base period and projection period
  2. Projection base rate: trending forward to projection period
  3. Claims data converted to an incurred basis including IBNR
  4. Inc claims matched with exposure to develop PMPM
  5. Actuarial cost model: PMPM by service category and produce codes
  6. PMPM medical cost = (the annual utilization per 1000) * (avg charge per service) /12000 - PMPM cost sharing
  7. Retention: converts medical cost to PMPM premium
  8. Conversion of rates from member to EE level
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4
Q

Managing the business
Examples of typical ongoing actuarial reports
Financial Gain/Loss Summaries AND Large Group-Specific Reports

A
  1. Financial Gain/Loss
    1. 1 Total block of business
    2. 2 Line of business (commercial vs Medicare)
    3. 3 Product line (HMO vs PPO, traditional vs CDHP)
    4. 4 Group size (large vs small group)
    5. 5 Type of business (new bs renewal)
    6. 6 type of medical service (hospital inpatient, outpatient, etc)
    7. 7 Calendar year or quarter
    8. 8 Each group individually (usually large group)
  2. Large group-specific reports
    1. 1 Earned premium
    2. 2 Paid claims
    3. 3 Medical loss ratio
    4. 4 Large claim information
    5. 5 Benefit plan changes
    6. 6 subscriber and membership counts by contract type
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5
Q

Managing the business
Examples of typical ongoing actuarial reports
Incurred claim costs

A
  1. Total block of business
  2. Line of business
  3. Product line
  4. Group size
  5. Type of business
  6. Funding arrangement
  7. Geographical area
  8. Policy duration of individual/small group (not usually applicable to large groups)
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6
Q

Managing the business
Example of typical ongoing actuarial reports
IBNR

A
  1. IBNR development
    1. 1 paid claim triangles
    2. 2 a lag development of incurred claims
    3. 3 a projection development of incurred claims
    4. 4 paid claim lags to monitor the speed of claim processing
    5. 5 analysis of seasonality/working days
    6. 6 medical cost trends, along with monthly, quarterly, and annually incurred claim estimates
  2. IBNR Reports
    1. 1 Line of business (commercial vs Medicare)
    2. 2 product line (HMO vs PPO, traditional vs CDHP)
    3. 3 Type of medical service (hospital inpatient, outpatient, etc)
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7
Q

Type of underwriting depends on

A
  1. Type of UW depends on:
    1. 1 the time (e.g at issue, during the plan year, or renewal)
    2. 2 group size
    3. 3 risk arrangement (fully insured and self-insured)
  2. UW at issue
    1. 1 health status and preexisting condition limitation not allowed under ACA
    2. 2 Ensuring a valid ER-EE relationship, min participation, Ability to pay, other coverage, persistency
  3. Underwriting during the plan year and at renewal
    1. 1 ACA does not prohibit experience rates for large groups
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8
Q

Managing the business
Examples of typical ongoing actuarial reports
Membership

A
  1. Line of business
  2. Product line
  3. Group size
  4. Type of business
  5. Contract tier
  6. Geographical area
  7. Age and gender
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