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Actuarial Risk Management (A311) 2021 > Chapter 7 - Health Insurance Products > Flashcards

Chapter 7 - Health Insurance Products Flashcards

1
Q

Main types of healthcare products

A
  1. Private medical insurance
  2. Critical illness
  3. Long-term care
  4. Other products and cash benefits
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2
Q

4 Aspects to consider in product design (Healthcare)

A
  1. Customer acceptability
  2. Regulatory requirements
  3. Price competitiveness
  4. System capabilities

CPRs

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3
Q

Types of underwriting for short-term contracts (5)

A
  1. Full medical underwriting: any excluded
  2. Moratorium underwriting: any in term excluded
  3. Medical history disregard: no exclusions
  4. No worse terms: at least as previous
  5. Continued personal medical exclusion: only as previous
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4
Q

How can medical expenses cover be limited under PMI? (7)

A

PMI products will vary according to:
1. Overall financial LIMITS and/or sub-limits

  1. The level of the REIMBURSEMENT RATE for specific healthcare services
  2. Whether the covered services are limited to a NETWORK of healthcare providers
  3. Whether to provide OUT-OF-SERVICE hospital benefits
  4. Whether to include medical SAVINGS accounts
  5. Benefits required by LEGISLATION
  6. RISK transfer mechanisms
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5
Q

List 6 typical activities of daily living

A

WTF DMT

  1. Washing
  2. Dressing
  3. Feeding
  4. Toileting
  5. Mobility
  6. Transferring
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6
Q

Key features of short term contracts

A
  1. Cover is typically provided for a single year and can then be renewed
  2. There can be multiple claims
  3. Claims are generally unknown and can be volatile
  4. There can be delays in reporting and settling of claims
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7
Q

What customer needs does PMI meet?

A

If no state-funded care exists, then PMI will usually provide for all forms of healthcare needs on an indemnity basis.

If the State provides some level of healthcare to all, then PMI is usually bought when an individual requires care such as:

  1. medical attention without waiting
  2. medical attention in a higher standard of accommodation
  3. medical attention with a doctor of choice
  4. medical attention in a local or private hospital
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8
Q

5 Aspects of healthcare markets that distinguish it from other markets

A
  1. Public good characteristic and universal access
  2. Information asymmetry, over-supply and demand
  3. Information about the range and quality of healthcare services relative to cost is difficult, if not impossible, for consumers to obtain.
  4. Rapidly increasing costs of healthcare services
  5. Importance of health insurance
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9
Q

Describe the importance of health insurance

A

There is a high level of uncertainty surrounding
FUTURE HEALTH, and thus uncertainty around the
TIMING and
NATURE OF SERVICES needed.

Healthcare needs INCREASE WITH AGE.

Individuals can provide for these costs through savings and insurance products. They are likely to underestimate the need to plan financially.

This adds extra pressure to employer-funded or state-funded systems.

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10
Q

Define long-term care insurance

A

LTCI can be defined as all forms of…

CONTINUING PERSONAL or NURSING CARE and associated domestic services for people who are…

UNABLE TO LOOK AFTER THEMSELVES without some degree of support, whether provided in their own homes, at a day center, or in a state-sponsored care-home setting.

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11
Q

Why may long-term insurers require reinsurance?

A
  1. They need to cope with claims fluctuations
  2. They need to finance new business strain
  3. They need to obtain technical assistance and data for pricing new contracts
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12
Q

List the key risks under healthcare products (10)

A
  1. Claim frequency, benefit amount, volatility and settlement delays
  2. Accumulations of risk, catastrophes, and a large number of large risks
  3. Investment risk
  4. Expenses being higher than expected
  5. Poor persistency, i.e. high lapses and low renewals
  6. Poor plan mixture due to upgrades, downgrades and anti-selection
  7. Underwriting risk
  8. Credit risk
  9. Operational risk
  10. Availability of claims data
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13
Q

List 4 entities that may be involved in the provision of healthcare services and health insurance

A
  1. State provision and NHI
  2. Subsidized healthcare through donor organizations
  3. Mutual companies (medical schemes)
  4. Insurance companies
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14
Q

Why may short-term insurers require reinsurance?

A
  1. They need to protect against large claims
  2. They will be able to take on larger risks and more risks than they otherwise could, due to capital constraints.
  3. They can reduce the impact of accumulations of risk and catastrophes
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15
Q

Describe ‘negotiated fee for service’

A

The tariff or remuneration rate for each type of service is defined through negotiations or being defined in advance.

This may lead to policyholders having to cover part of the costs through out of pocket payments.

(additional info: Under fee-for-service, you choose the doctor or the hospital or the clinic, and the insurance pays for part or all of the cost according to a schedule laid out in the policy.)

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16
Q

Describe ‘Global fee’

A

There is a FIXED TARIFF/fee PER EPISODE OF CARE with the service provider, assuming some risk for the level of services required per patient.

(e.g. maternity or a knee replacement)

17
Q

Describe ‘Capitation’

A

A fixed amount is paid (to healthcare service provider) per policyholder / beneficiary who has the option to use the service.

The fee is paid regardless of whether the service is used or not.

This transfers the risk from the insurer to the provider of services

(additional info: Capitation is a payment arrangement for health care service providers. It pays a set amount for each enrolled person assigned to them, per period of time, whether or not that person seeks care.)

18
Q

What customer need does CI cover meet? (6)

A

NOTE: This product is not designed to indemnify the policyholder.

The needs met include:
1. To provide a source of INCOME if unable to work

  1. Can assist with REPAYMENT OF LOAN or mortgage
  2. Medical costs can be funded when surgery or expensive treatment is required
  3. Could be used by business partners to BUY OUT a partnership stake in a business when CI arisies
  4. Can be used to fund a change in LIFESTYLE that is required
  5. Can provide for RECUPERATION after illness
19
Q

Difference between indemnity cover and stated benefit cover

A

Indemnity cover provides benefits related to the loss incurred on the occurrence of the health event.

For stated benefit cover, the policy document defines the benefit that is payable on the occurrence of a defined health event, regardless of the actual loss incurred.

20
Q

Define Private Medical Insurance (PMI)

A

PMI (and related products) are usually INDEMNITY-based products that seek to provide COMPENSATION for the COST of private medical TREATMENT.

The extent of the cover will depend on the level and quality of State services offered in a specific country.

21
Q

Key features of long-term contracts

A
  1. They are long term
  2. Cover usually ceases on claim
  3. The claim amount may be known with certainty (ie fixed sum)
  4. Used for protection against ill health or death, as well as savings.
  5. Group versions are typically only for 1 or 2 years, but can then be renewed
22
Q

Does a group version of PMI exist?

A

Yes.

Employers often use them to cover several employees.

Benefits and exclusions are generally similar between group and individual contracts.

Pre-existing conditions are more likely to be covered under group business due to a lower degree of anti-selection.

23
Q

5 Factors to consider in good scheme design for group products.

A
  1. Applying exclusions
  2. Setting free cover limits
  3. Ensuring members are actively involved at work when cover begins.
  4. Setting take up rates on voluntary schemes
  5. Laying down take over terms when the insurer accepts a scheme previously insured elsewhere
24
Q

What are open medical schemes?

A

Open medical schemes are obliged to accept anyone who wants to become a member at standard contribution rates, and at a minimum benefit package is prescribed under legislation

25
Q

What is solidarity?

A

Solidarity is similar to mutuality in that they both involve the concept of sharing losses.

However the main differences are:
1. Under solidarity principles, the PREMIUMS ARE NOT BASED ON RISK, but rather on the ability to pay, or premiums are set equally.

  1. Under solidarity principles, losses are paid according to need.
26
Q

What need does LTC insurance meet?

A

Usually aims to provide financial protection when a person becomes unable to look after themselves

27
Q

Does a group version of CI cover exist?

A

Yes.

The key requirements to establish a group scheme are:
1. There is a definition of who is eligible for the benefits under the scheme

  1. The benefits under the scheme are clearly defined by:
    - size
    - definition of valid claim
    - the period of the benefit
28
Q

List the 4 reimbursement mechanisms for healthcare costs. (Low risk to most risk transfer)

A
  1. Fee for service
  2. Negotiated fee for service
  3. Global fee
  4. Capitation
29
Q

Describe ‘Fee for service’

A

Providers are reimbursed for each service provided.

No restrictions apply on the cost of the service.

30
Q

What values need to be determined when setting premium / contribution rates?

A
  1. Claims
  2. Expenses
  3. Commission
  4. Risk transfer arrangements
  5. Non-premium income
  6. Reserve loading requirements
31
Q

Does a group version of LTCI exist?

A

Not commonly.

32
Q

Describe the principle of mutuality in healthcare

A

A pooled fund is created and premiums are paid into the fund by policyholders.

The premium paid by the policyholders is determined by the RISK presented by the policyholder at the time of taking out the contract.

Claims are paid out of the pooled funds in accordance with the policyholder agreement.

33
Q

What is the main type of reserve required in healthcare?

A

Incurred bu not yet reported (IBNR).

This is a reserve for claim events that have occurred but which the healthcare provider does not yet know about.

34
Q

What is an affinity group?

A

A group of people who share a common interest, background or goal and are linked together by being members of the same organization.

35
Q

List 4 other types of PMI-related products

A
  1. Major medical expenses
  2. Hospital cash plans
  3. Medical shortfall (gap) cover
  4. Personal accident
36
Q

JUST READ

Mutuality: Pool risks but pay according to risk.

Solidarity: Pay equally or income-rated.

Community rating: Premiums charged on overall claims
experience rather than individual/group.

Open enrolment: Cannot deny cover. PMBs.

A

.

Actuarial Risk Management (A311) 2021 (26 decks)

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