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15 Cards in this Set
- Front
- Back
NEW BUSINESS UNDERWRITING
Characteristics of the Group to consider during underwriting and pricing: See “General–Rating Factors” for a consolidation of this list with similar lists. |
(A) ge and (S) ex
Best indicators of morbidity. (H) ealth Only underwritten on high LI policies. (F) amily Size (I) ndustry Important for DI. (L) ocation Costs vary between rural/urban areas. (E) Environment; Smoking (O) ffsets Workers’ Comp, Medicare, and Social Security lower the insurer’s costs. (A) ntiselection controls Minimum participation requirement (F) eatures of the product See “Designing The Plan”, below (F) inancial Viability and Carrier Persistence If group switches carriers, insurer will not recoup acquisition cost. (E) ase of administration Homogeneous = best. Multiple types of ees and customized plans = hardest. Best if employer has accurate enrollment and termination data. (Z) siZe of group Larger better economy of scale. (P) Prior Experience See “Evaluating The Experience”, below (O) verstaffed companies / Companies with high Turnover Problems: Increased admin costs. Portability regulations. Anticipation of layoffs causes a flurry of claims. (T) ype of Group See “Special Risks (Special Types Of Groups)”, below. |
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Designing a Large Group Insurance Plan
The following safeguards help control antiselection and plan costs: Life Insurance |
Main risks: Volatile experience;
Antiselection. Recommendations: Min. participation requirement Require EOI for high amounts Reductions in face value for older employees Open enrollment period only. |
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Disability Insurance
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Main risks: Volatile, long-period claims
Claims are subjective; can be falsified Recommendations: Elimination periods Don’t reimburse 100% of salary Offset vs. Workers Comp or Soc Sec. Encourage limited-duty return to work, rehabilitation, etc. Don’t insure high-turnover groups. |
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Health Insurance
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Health Insurance
Recommendations for Traditional HI Include deductibles and coinsurance. Limit covered services. Recommendations for Managed Care HI Give ees financial incentives to: Use preventive care Use in-network doctors Require pre-authorizations |
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Dental and Vision Plans
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Main risk: Elective Vulnerable to antiselection.
Recommendations: Min. participation requirement Cover 100% of preventive care only. Package the dental/vision plan with the health plan |
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Evaluating the Group’s Prior Experience
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Data comes from the employer and from the prior insurer.
Considerations in Using a Group’s Past Claims to Project Future Claim Costs: Are the past claims credible? Is the data accurate and complete? How must I adjust the data to be on the same scale as our proposed plan? Credibility Issues Smaller groups less credible. Low-frequency, high-severity coverages less credible. (LI and DI least credible; HI most credible) Ways to Cope with Volatile, Non-credible Data: Use manual rating Look at several years of data Pool large claims Data Accuracy Issues Look at the prior insurer’s public financial statements. Did its IBNR reserves match the runout? Were premiums consistent with the demographics? Were its claim patterns real, or were they just due to administrative difficulty? Data Adjustments Data from the previous experience must be adjusted for: Trend Business cycles One-time anomalies (remove) Increased antiselection (e.g. if you are adding more plan options) Managed Care Plan Differences between your HMO and the previous one: Location of doctors Network size In-network usage % (for PPO/POS) Provider contract differences (type of contract; level of discount) Difficult to find out about prior carrier’s contracts. Services falling under different contracts Degree of utilization management See example in Detailed Chapter Notes |
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RESPONDING TO A REQUEST FOR PROPOSAL
Contents of a Typical Employer’s RFP |
Claim experience reports (utilization; cost)
Questionnaires for the insurer: Its utilization figures Its cost management ability Its financial performance Specifications for the desired plan Carve-out options desired Funding method desired (full insurance, stop-loss, or ASO) Risk-sharing arrangements; performance guarantees (for ASO contracts) Performance guarantees can be based on: claim speed / accuracy employee satisfaction quality of care |
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A Good Response to an RFP
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Goal: Create a product that is financially sound given the group, plan design, and prior claims, yet attractive to the employer.
The insurer’s offer should include: Price Underwriting controls Assumptions: Level of employer contributions Demographics Ee participation % Right to Cancel the offer if assumptions are not met Performance Guarantees Breakdown of expense charges Suggested alternate plans |
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Difficulties in Responding to a Large Group RFP
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Large groups have:
Unique populations Customized plan needs Special funding methods Judgment is needed in pricing. |
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RENEWAL UNDERWRITING
Evaluate the Year’s Experience, with respect to: |
Enrollment changes
Ee participation levels Antiselection level Catastrophic claims (if any) IBNR reserve Claim runout pattern This analysis should be split by age, sex, location, etc. |
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Difficulties
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Need to quote next year’s rate before this year is complete.
As a result: Claims not mature IBNR not confident Can’t tell whether large claims are “typical” |
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Develop Renewal Recommendations
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Quote new premium rates.
If unattractive, then: Offer a new funding method (e.g. retrospective premium) Propose design changes, e.g. Cost-sharing Utilization review Reducing retiree costs (via Medicare) Or any of the other antiselection and cost controls from “(F)eatures of the product”, above. This would make a good exam question. |
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Proactively Develop Plan Revisions
Do Renewal Monitoring |
Track emerging experience throughout the year.
Reasons why: For financial reporting For internal control For cash flow planning (e.g. eoy settlements) To identify trends and take corrective action To keep employer informed |
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SPECIAL RISKS (SPECIAL TYPES OF GROUPS)
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Association Programs
Risks to Underwriter: Low member participation high antiselection MET’s (Multiple Employer Trusts) MEWA’s have history of insolvency. Taft-Hartley Plans Total income into trust must equal total admin cost and benefit cost for all the ees. Purchasing Alliances Several employers using a common RFP and a common plan design. Reasons: (a) better bargaining power; (b) Get lower prices by offering economies of scale. Risks to Underwriter: Strong negotiating power May demand the same premium for all ers May form a high percentage of the insurer’s market share. |
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Plan Design for These Special Types of Groups
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The insurer should require (similar to “Designing The Plan”, above)
High er contribution High ee participation EOI for large LI amounts Preexisting condition exclusions Done. |