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11 Cards in this Set
- Front
- Back
THE SMALL GROUP MARKET
Typical Small Group Plans |
Medical
Many small employers cannot afford HI High ee contributions and cost-sharing Key employees only, sometimes. Life Insurance Small face amounts; packaged Disability STD is rare; LTD more common. |
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Why Antiselection Is High in Small Groups
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Er has first-hand knowledge of the ees’ health
Cost pressures Er only buys insurance when it’s needed Guaranteed Issue regulations HIPAA Requirements for Insurers of Small Groups: Guaranteed issue; Guaranteed renewal Cannot reject any employee because of his health Must offer all plans Required pregnancy coverage Portability State Laws States limit premium variation by demographics |
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Distribution Sources – Sales and Marketing to Small Groups
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Noncaptive agents, except for larger groups
Internet sales becoming common (UW still manual) Commissions Level, or first-year higher Vary by group size Should encourage “field underwriting” The Small Group Competitive Environment Winners: National carriers; BCBS’s; HMOs Losers: Mid-size and Small carriers Summary: Recommendations and Difficulties for Insurers in the Small Group Market A small group insurance carrier needs to understand: The competition Market volatility; changing regulations Plan designs that maximize cost control Regulations HIPAA Differing state laws Compliance-related expenses |
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UNDERWRITING FACTORS
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Evaluate: 1) The individual ees; 2) The employer entity as a whole.
(A) ge and (S) ex States limit allowable rating spread causes demographic risk to insurer Young ees subsidize old; males subsidize females (H) ealth of ees Critical in small group underwriting. Ees underwritten individually by: “Short-form”, “long-form”, or medical exam UW information includes: APS; drug info; blood tests. Note: APS = Attending Physician’s Statement Considerations in health status underwriting for small groups: Admin. expensive; must weigh costs vs. possible savings in claims Amount of risk transferred to providers: Capitated providers less UW required, but: Consider provider’s risk tolerance. (F) amily Size 2, 3, or 4-tier structure Family rates computed exactly, or using assumed age/sex distributions Cheaper/easier, but riskier. (I) ndustry Cannot reject a group based on industry Premium adjustment limited by law (L) ocation — compensate for: Claim cost variation Provider contract variations Marketing expenses (E) Environment; Smoking (O) ffsets vs. Workers Comp or Medicare (A) ntiselection controls Minimum Participation req. Min Contribution req. Consumer-driven defined-contribution plans have lower claim costs. Pre-existing condition limitations Difficulties: Portability laws prevent its use Laws vary for new entrants vs. late entrants. Eligibility Rules Waiting period of 1-3 months Full-time, actively-at-work requirement Dependents < 19 only Optional benefits electable only at issue. (F) eatures of the product Plan richness; managed care savings Cannot vary rates based on assumed antiselection (F) inancial Viability and Carrier Persistence Will not recoup acquisition cost if company fails or switches. (Z) siZe of group Larger safer and cheaper, b/c: Risk is spread over more ees Admin costs lower Antiselection lower Note: Verify group’s size to see if HIPAA applies (P) Prior Experience / Past claims Why is group seeking coverage now? Difficulties: Small groups’ past claims are not credible (O) verstaffed companies / Companies with high turnover Higher admin cost/difficulty Higher antiselection (T) ype of Group (Single-er or MET) |
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HOW THE UNDERWRITING FACTORS ARE USED
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Insurers must keep a rate manual, which:
Lists loading factors for Age, Sex, Family composition, Industry, Location, Features of the product, and Group size. (A, S, F, I, L, F, and Z) Complies with state laws (may have more than one rate manual) Is certified by an actuary Premium charged = New business premium usually low, for competitivity times Manual age, sex, industry, etc. factors times Adjustments for health, prior claim cost, duration |
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RENEWAL RATING STRUCTURES – DURATIONAL AND TIERED RATING
Claim costs increase steeply after the first year, because: |
Underwriting wears off
Pre-existing exclusions expire Calendar-year deductible was applied in first year |
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Durational Rating
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Charging a group more every year regardless of claims
Forbidden in most states. |
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Tiered Rating (also called Band Rating or Formula-Based Rating)
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Create several loss ratio bands; each gets its own rate increase
States limit the allowable rate increase. |
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Difficulties with Tiered Rating
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Small group experience is not credible
May overcharge a healthy group (uncompetitive) or undercharge a sick one |
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Solutions
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Pool large claims
Examine causes of the claims (expensive) Use risk predictor software. |
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STATE RISK-POOLING PROGRAMS
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Reinsurance Programs
Risk-Adjustment Programs Goals: Limit risk from Guaranteed Issue and pricing restrictions Limit catastrophic claim risk Spread risk among insurers Done. |