Medical Claim Costs Flashcards
1
Q
Medical Claim Costs
Types of Data to Collect for Manual Rates
A
- Financial data (how much)
- Experience period (when)
- Exposure basis (who)
- Frequency of data collection (how often)
2
Q
Medical Claim Costs
What rating variables need to be normalized?
A
- Age/gender
- Geographic area
- Benefit plan
- Group characteristics
- UM programs
- Provider reimbursement arrangements
- Other risk adjusters (based on claims data)
3
Q
Medical Claim Costs
Secular Trend
A
% change from factors affecting the 1st dollar, 100% of benefits
- Impacts all plans, regardless of mix
4
Q
Medical Claim Costs
Types of Trend
A
- Unit cost
- Utilization
- Mix of services
- Provider Reimbursement
- Technology
- Drugs
- Plan Design
5
Q
Medical Claim Costs
Methods of Adjusting Manual Base Rates and Uses
A
- Claim Probability Distributions = Major medical plans with cost-sharing
- Actuarial Cost Models = Copays
6
Q
Medical Claim Costs
Evolution of UW and Rating
A
- HIPAA = small groups had to offer medical on guaranteed acceptance and renewal basis
- ACA
- EHB, standardized plans
- Removed rating variables and other limitations
7
Q
Medical Claim Costs
Experience Considerations for Insurers for Small Group Rating
A
Can’t rate on these factors, but they can help understand drivers of experience
- Financial viability
- Industry/Occupation
- Group size
- Workers compensation
- ER contribution
- Prior coverage
8
Q
Medical Claim Costs
Allowable Criteria for Underwriting Small Groups
A
- ER is licensed
- Participation and contribution requirements outside of open enrollment period
- EE Eligibility requirements
- Enforcement of ER restrictions on coverage for late entrants (waiting periods)
9
Q
Medical Claim Costs
Allowable Rating Parameters for Small Groups Under ACA
A
- Age (3:1)
- Geographic Area
- Benefit Plan
- Managed Care and Negotiated Discounts
- Family Composition
- Tobacco Use
