Private Health Insurance Premiums and
Rate Reviews
Mark Newsom
Specialist in Health Care Financing
Bernadette Fernandez
Specialist in Health Care Financing
January 11, 2011
Congressional Research Service
7-5700
www.crs.gov
R41588
CRS Report for Congress
P
repared for Members and Committees of Congress
Private Health Insurance Premiums and Rate Reviews
Summary
In general, the premiums charged by health insurance companies represent actuarial estimates of
the amount that would be required to cover three main components: (1) the expected cost of the
health benefits covered under the plan, (2) the business administrative costs of operating the plan,
and (3) a profit. The final premium calculation often is adjusted upward or downward to reflect
several factors, such as making up for a previous financial loss.
Health insurance premiums have been trending up, while the value of coverage has trended down.
Available data indicate that both administrative and medical costs continue to rise, but the rate of
growth in these expenses slowed between 2008 and 2009. The data also suggest that the rise in
medical costs is primarily attributable to the price of services, not increased utilization.
The rise in the cost of health insurance has received considerable attention by Congress and
resulted in calls for more regulation. The regulation of private health insurance has traditionally
been under the jurisdiction of the states. Most states have used their regulatory authority over the
business of insurance to require the filing of health insurance documents containing rate
information for one or more insurance market segments or plan types. With the enactment of the
Patient Protection and Affordable Care Act (P.L. 111-148, PPACA) on March 23, 2010, and
subsequent amendments, the federal government will assume a role in private health insurance
rate reviews by providing grants to states and requiring health insurance companies to provide
justifications for proposed rate increases determined to be unreasonable.
This report provides an overview of the concepts, regulation, and available public data regarding
private health insurance premiums. This report will be updated to reflect relevant legislative
activity and the availability of new public data.
Congressional Research Service
Private Health Insurance Premiums and Rate Reviews
Contents
Introduction ................................................................................................................................ 1
Drivers of Premium Increases ..................................................................................................... 4
Health Benefits Expenses ...................................................................................................... 4
Unit Prices ...................................................................................................................... 6
Health Service Utilization ............................................................................................... 7
Administrative Costs............................................................................................................. 9
Health Insurance Company Profits ...................................................................................... 11
The Underwriting Cycle...................................................................................................... 13
Review of Health Insurance Rates ............................................................................................. 14
State Rate Filing and Reviews ............................................................................................. 15
Federal Reforms Affecting Premiums.................................................................................. 19
Figures
Figure 1. Year-Over-Year Percentage Change in Premiums for January and Average for
All Other Months, 2004-2010................................................................................................... 3
Figure 2. Per Member Per Month (PMPM) and Annual Percentage Increases in Health
Benefits Expenses for the Health Insurance Industry, 2002-2009 .............................................. 5
Figure 3.Average Health Insurer Administrative Costs Per Company, 2007-2009....................... 10
Figure 4. Health Insurance Company Profit Margins, 2009........................................................ 12
Figure A-1. Average Deductibles, by Health Insurance Plan Type, CY2007-2009 ...................... 24
Tables
Table 1. Average Employer and Worker Shares of Total Premium Costs, 2001-2008.................... 4
Table 2. Summary of Health Insurance Administrative Functions ................................................ 9
Table 3. Quotes from Health Insurance Executives About Administrative Costs......................... 11
Table 4. Anthem Individual Health Insurance Rates for Policies in California ............................ 14
Table 5. State Rate Filing Requirements, by Market Segment, 2010........................................... 16
Appendixes
Appendix. Private Health Insurance Cost-Sharing ..................................................................... 23
Contacts
Author Contact Information ...................................................................................................... 24
Congressional Research Service
Private Health Insurance Premiums and Rate Reviews
Introduction
Health insurance premiums represent a contractually agreed upon amount to be paid for a defined
set of health benefits during a defined period of time (usually a year). Premiums are typically paid
in monthly installments by policyholders (individual coverage) and enrollees (group coverage).
Premiums may vary for different individuals with the same health benefits package from the same
insurance company. Each variation is referred to as a premium rate. Rating methodologies
generally vary between health insurance market segments and may have additional state-specific
variation due to differences in state rate regulations.1 Typically, the following methods are used
by market segment:
• Individual health insurance market. Rates vary by age and gender and may
also be underwritten, meaning that the health status assessed by the past health
conditions of individual are used to set the rate according to the health risk of the
applicant.
• Small group market. What is called a “manual rate” is first calculated
estimating the costs by the age and gender of the employees, geographic location,
number of employees, and the type of health insurance product.2 Most states also
permit the manual rate to be adjusted by a health status factor.
• Large group market. Premium rates are determined either from an individual
group’s medical claims history (referred to as “experience”) or from a blended
average of manual rates calculated from the members of the group and from the
group’s experience.3
Health insurance premium rates are actuarial estimates of the cost of covering a risk pool of
individuals under a particular health benefits package for a particular period of time.4 Generally,
the more generous the benefits package (i.e., large, open networks of providers and low cost
sharing including deductibles) the higher the premiums will be. Just as premiums must be
adequate to pay for expected health care use, they also must be sufficient to compensate insurance
carriers for taking on the financial risk associated with providing coverage.
1 The three private health insurance market segments are individual, small group, and large group. They are defined at
§2791(e) of the Public Health Service Act (PHSA). The term “individual market” means health insurance coverage
offered to individuals (and potentially their dependents) that is not in connection with a group health plan. The
determination of whether an employer is large or small depends on its average employment level for the year. Prior to
PPACA, the PHSA defined a small group in terms of 2-50 employees, and a large group in terms of 51 or more
employees. Section 1304(b) of PPACA amended these definitions so that a small employer is one with 1-100
employees and a large employer has 101 or more employees. However, section 1304(b)(3) of PPACA allows states to
continue to define an employer with up to 50 employees as a ‘‘small employer’’ until 2016.
2 The term “insurance product type” refers to substantive differences in plan design (e.g., no deductible versus a high
deductible) that would reasonably be expected to affect the utilization of medical care.
3 For more information on the use of different health insurance rating methodologies, see John Bertko, “Health
Insurance Market Rating Practices,” September 2008, available at http://www.rand.org/pubs/testimonies/CT315/.
4 Health insurance actuaries apply mathematical expertise, statistical knowledge, economic and financial analyses, and
problem-solving skills to help health insurance companies evaluate ways to manage risk. For more information on
actuarial science, see American Academy of Actuaries, “Becoming an actuary,” 2010, available at
http://www.actuary.org/becoming.asp.
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The final premium rate calculation often is adjusted to reflect several other factors, such as
making up for a previous financial loss and providing excess capital to manage various risks
generally regulated under state solvency standards. State regulators have adopted solvency
standards to protect consumers by requiring insurance companies to keep certain reserves of
capital to protect against asset risks, underwriting or insurance risk, and business risks.5 Without
this required safety net of reserved cash, a health insurance company could go bankrupt if it
experiences unforeseen losses, thus resulting in its consumers being placed at full financial risk
for their medical claims.
Data from the Bureau of Labor Statistics’ (BLS’s) Producer Price Index (PPI) for health insurance
companies indicates that the year-over-year percentage increase by month in private health
insurance premiums has averaged around 4.4% between 2004 and 2010, but has accelerated since
2009, ranging from 4.8%-5.5% (Figure 1).6 This may not seem like a large amount, but there are
four relevant contextual factors to take into consideration. First, increases can be much higher in
the individual and small group markets where the smaller risk pools can result in distortions in the
average health care costs covered by premiums, due to outlier policyholders or members. In other
words, if there are only a few healthy persons to help pay for a sick person, the premiums (all else
being equal) will be higher than if that sick person was in a larger risk pool with many healthy
persons. Second, in the employer group market, the out-of-pocket cost of premiums for
individuals and families has been increasing even more because employer subsidies have been
trending down. The employer and workers shares vary according to coverage tier: self-only,
employee-plus-one, and family. However, in the past few years employers have shifted
incrementally more of that cost to workers. For example, the average worker share of the total
premium for group coverage was 19.9% in 2001 and grew to 23.3% by 2008 (Table 1). Third, as
premiums have gone up, the value of the coverage has gone down in terms of higher cost sharing
and deductibles (see the Appendix). Fourth, both per capita and family incomes have decreased
about 2% between 2004 and 2010.7 As a result, incomes are not keeping up with premium
increases, and a greater proportion of incomes are being consumed by health insurance
premiums.8
This growth of health insurance premiums and the out-of-pocket costs for individuals and
families has been the focus of considerable congressional attention.9 Using available public data,
5 The term “asset risk” means the potential for a default of principal and interest or loss in fair value of assets such as
bonds, loans, real estate, and stock. The term “underwriting or insurance risk” refers to the risk that medical expenses
will exceed the premiums collected. The term “business risk” refers to the variety of general operational risks to the
insurance company such as unexpected increases in labor costs and exposure to litigation. For a general overview of
solvency standards, see National Association of Insurance Commissioners, “Risk-Based Capital General Overview,”
July 2009, available at http://www.naic.org/documents/committees_e_capad_RBCoverview.pdf.
6 In the case of employer group coverage, the PPI survey takes into account the amount paid by the employer. Year-
over-year refers to a comparison of prices to the same time period in the previous year, such as a month or quarter. For
example, comparing the percent change in prices in January 2009 to the prices in January 2010. This type of analysis is
appropriate for health insurance because coverage typically begins on the first of each month and the duration of the
coverage is typically a year.
7 U.S. Census Bureau, “Historical Income Tables: Current Population Survey Tables,” September 2010, available at
http://www.census.gov/hhes/www/income/data/historical/index.html.
8 Cathy Schoen et al., “State Trends in Premiums and Deductibles, 2003–2009: How Building on the Affordable Care
Act Will Help Stem the Tide of Rising Costs and Eroding Benefits,” The Commonwealth Fund, December 2010.
9 For example, see U.S. Congress, House Committee on Ways and Means, Health Reform in the 21st Century:
Insurance Market Reforms, 111th Cong., 1st sess., April 22, 2009 (Washington: GPO, 2009); U.S. Congress, House
Committee on Education and Labor, Subcommittee on Health, Employment, Labor and Pensions, Ways to Reduce the
(continued...)
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Private Health Insurance Premiums and Rate Reviews
this report explores the potential drivers of the growth trend in health insurance premiums.10
Specifically, this report analyzes the four broad components of health insurance premiums:
medical claims, administrative costs, profit, and miscellaneous factors often referred to as the
underwriting cycle. Finally, the report discusses state requirements to review health insurance
rates, and relevant rate regulation provisions under federal health reform.
Figure 1. Year-Over-Year Percentage Change in Premiums for January and Average
for All Other Months, 2004-2010
8.0%
7.3%
7.0%
6.0%
5.5% 5.4%
5.0%
5.1%
4.9%
5.0%
4.5%
4.5%
4.2%4.2%
4.0%
3.7%
4.0%
3.3%3.0%
3.0%
2.0%
1.0%
0.0%
2004
2005
2006
2007
2008
2009
2010
January 12-Month % Change
Average 12-Month % Change (Feb.-Dec.)
Source: U.S. Department of Labor, Bureau of Labor Statistics (BLS), “Producer Price Index Industry Data,”
2010, available at http://data.bls.gov/PDQ/servlet/SurveyOutputServlet?series_id=PCU524114524114.
Notes: The year-over-year percentage change is isolated for January because most group plans are sold for 12-
month durations beginning on January 1 of each year. Individual market health insurance products are sold
monthly and usual y for a 12-month duration. Thus, the average monthly year-over-year % change for February
through December is presented. The indexes for this industry measure the change in the total premium
(employee and employer contribution) paid to the insurer plus the return on the invested portion of the
premium. For more information on the survey methodology, see U.S. Department of Labor, Bureau of Labor
Statistics (BLS), “Producer Price Index for the Direct Health and Medical Insurance Carriers Industry – NAICS
524114,” September 2005, available at http://www.bls.gov/ppi/ppimedicalinsurance.htm.
(...continued)
Cost of Health Insurance for Employers, Employees and their Families, 111th Cong., 1st sess., April 23, 2009
(Washington: GPO, 2009); U.S. Congress, Senate Committee on Commerce, Science, and Transportation, Consumer
Choices and Transparency in the Health Insurance Industry, 111th Cong., 1st sess., June 24, 2009 (Washington: GPO,
2009); and U.S. Congress, Senate Committee on Health Education Labor and Pensions, Protection from Unjustified
Premiums, 111th Cong., 1st sess., April 20, 2010, available at http://help.senate.gov/hearings/.
10 The health insurance company financial data that could most directly demonstrate specific plan level medical and
administrative expenses that drive premiums generally is proprietary and confidential. Regulatory filings such as those
with the Securities and Exchange Commission or the state insurance commissioners are reported at the legal entity or
parent organization level. In other words, aggregate financial data for an entire company or the company within a state
do not reflect the variations in both premiums and costs observed in each of the multiple plans offered by a single
organization.
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Private Health Insurance Premiums and Rate Reviews
Table 1. Average Employer and Worker Shares of Total Premium Costs, 2001-2008
2001 2002 2003 2004 2005 2006 2008
All Coverage Tiers
Employer
Share
80.1% 79.7% 78.6% 78.8% 79.0% 78.1% 76.7%
Worker
Share
19.9% 20.3% 21.4% 21.2% 21.0% 21.9% 23.3%
Self-Only Coverage
Employer
Share
84.4% 83.7% 84.0% 83.5% 83.5% 82.7% 81.9%
Worker
Share
15.6% 16.3% 16.0% 16.5% 16.4% 17.3% 18.1%
Employee+One
Employer
Share
80.8% 80.2% 76.9% 77.1% 77.8% 77.0% 74.5%
Worker
Share
19.2% 19.8% 23.1% 22.9% 22.2% 23.0% 25.5%
Family Coverage
Employer
Share
77.9% 77.5% 76.5% 77.0% 77.1% 76.2% 74.7%
Worker
Share
22.1% 22.5% 23.5% 23.0% 22.9% 23.8% 25.3%
Source: Medical Expenditure Panel Survey-Insurance Component, Agency for Healthcare Research and Quality.
Notes: These shares are based on nominal premium amounts. Group premiums include coverage offered by
private firms and state and local governments. MEPS employer group health insurance premium data were
unavailable for 2007.
Drivers of Premium Increases
In general, the premiums charged by health insurance companies represent the estimated amount
that would be required to cover initially three major components: (1) the expected cost of the
health benefits covered, (2) the administrative costs of operating the coverage, and (3) a profit
margin consistent with the strategic business goals of the company.11 The fourth and final
component to the premium calculation involves adjustments upward or downward to reflect
several miscellaneous factors, such as responding to prior gains or losses, strategically responding
to competitors (i.e., pricing lower to gain market share), hedging against uncertainty risks created
by a changing regulatory environment, and other factors often collectively described as the
underwriting cycle.
Health Benefits Expenses
Health benefits expenses equal the aggregate of the unit prices of the health services times the
utilization of health services (e.g., hospital visits) or health items, such as prescription drugs.
11 Cost is the product of the price of health benefits and the utilization of those benefits. Profit margin is a financial
ratio used to assess the profitability of a firm. It equals revenue minus expenses divided by revenue. Different
organizations have different strategic business goals that can also change over time. Maximizing profit may not always
be the goal for a given time period. For example, a for-profit company may accept lower profit margins for a period of
time in order to gain more market share by offering a better price compared to the firm’s competitors. While non-profit
insurers do not seek to generate profit in the conventional sense, they have an incentive to reduce expenses in order to
invest retained earnings back into the organization for capital expenditures such as purchasing additional information
technology, expanding customer service operations, or other administrative activities.
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Private Health Insurance Premiums and Rate Reviews
Health benefits expenses represent the largest component of premiums. According to the
aggregate health insurance industry statements of revenue and expenses submitted to the National
Association of Insurance Commissioners (NAIC) in 2008, health benefits represented about 88%
of premiums.12
Health benefits expenses on a per member per month (PMPM) basis have trended upwards
between 2002 and 2009 in aggregate for the health insurance industry, as illustrated in Figure 2.
The term “member month” refers to each month of coverage for an enrollee or policyholder, thus
a member for a full year would have 12 member months. PMPM calculations are often used for
health insurance financial statistics because enrollments and premium payments are generally
made on a monthly basis. The annual percentage increase in total health benefits expenses,
typically referred to as the medical trend, has generally been over 7% per year, but the rate of
growth decelerated to 4.9% between 2008 and 2009, likely due to the macroeconomic conditions
for consumers during this period. The medical trend of a particular plan or policy can vary
substantively based on such factors as the relative health status of the enrollees and policyholders,
differences in coverage policy, differences in the use of managed care techniques, geographic
differences, use of restrictive versus open provider networks, and various organizational factors,
such as being for-profit or non-profit.
Figure 2. Per Member Per Month (PMPM) and Annual Percentage Increases in
Health Benefits Expenses for the Health Insurance Industry, 2002-2009
$300.00
4.9%
$250.00
7.0%
7.2%
8.1%
8.0
$200.00
7.8%
6.6%
$150.00
$249.48
$237.77
$222.15
$100.00
$154.58
$166.65
$177.58
$191.70
$205.59
$50.00
$0.00
CY2002
CY2003
CY2004
CY2005
CY2006
CY2007
CY2008
CY2009
Source: Debra Donahue, “Medical Expense Trend Declined in 2009,” July 22, 2010, available at
http://www.markfarrah.com/healthcarebs.asp?article=84.
Notes: This study was based on a representative sample of 393 health plans and insurance products from 181
different companies. Only companies that filed 2006 through 2009 Health Annual Statements with the National
Association of Insurance Commissioners were included. Excluded from the dataset were California HMOs and
self-insured health plans that are not required to file Annual Statements with the National Association of
Insurance Commissioners (NAIC) and specialty, non-medical plans such as dental insurers.
12 Rounded to the nearest tenth of a percent. Not all health insurance companies are required to report to NAIC. Most
notably self-insured employer groups nationwide and health maintenance organizations in California do not report to
the NAIC. National Association of Insurance Commissioners, “Statistical Compilation of Annual Statement
Information for Health Insurance Companies in 2008,” 2009.
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Private Health Insurance Premiums and Rate Reviews
Unit Prices
The unit price of health services and prescription drugs is determined through a contract
negotiation process between health insurance companies, health providers, medical device
companies, and drug manufacturers or distributors. There is evidence of considerable geographic
variation in provider, but not prescription drug pricing.13 The Government Accountability Office
(GAO) has reported that for private insurers with Preferred Provider Organizations (PPOs) in the
Federal Employee Health Benefits Program (FEHBP), hospital prices varied by 259% and
physician prices varied by about 100% across metropolitan areas.14 GAO attributed the variation
in prices paid by insurers to regional differences in provider bargaining power. Similarly, the
Center for Studying Health System Change has found evidence that providers may have a
negotiating advantage over insurers in some markets. In one study conducted in 2002-2003,
health care providers were found to have dominant negotiating power that afforded them the
opportunity to secure significant payment rate increases.15 Another study in six California markets
between October and December 2008 found that physician group practice integration with
hospital systems, hospital mergers, the desire for broad provider choice, growing physician
shortages, and a regulatory environment that favors providers all contributed to a price
negotiation advantage for some providers.16
The power of providers in negotiating higher unit prices has been recognized by some state
insurance commissioners that perform premium rate reviews. For example, in the reformed
Massachusetts market, the Division of Insurance approved (on appeal) a premium rate increase
for Fallon Community Health Plan after finding that, among other things, “individuals and
employer groups demand that Fallon provide options that include access to every doctor and
hospital, including local providers, as well as access to larger tertiary systems.”17 The
Massachusetts Division of Insurance Appeals Board concluded that “[m]arketplace realities mean
that Fallon sometimes has no choice but to contract with higher cost providers.” Similarly, an
investigation by the Office of the Massachusetts Attorney General concluded that large providers
with brand-name recognition have considerable leverage over all health insurance companies
when negotiating prices, and that price increases have accounted for the majority of the medical
trend in Massachusetts.18
13 Drug prices generally involve national-level negotiations between pharmacy benefit managers working on behalf of
health insurers and drug manufacturers or distributors. By limiting the number of negotiating entities and make the
negotiations more national in scope, the geographic variation of prescription drug prices is limited. By contrast, the
pricing of health services involves health insurance companies negotiating at the local level with thousands of
individual providers, provider groups, agencies, long-term care facilities, and hospitals.
14 Government Accountability Office, “Federal Employees Health Benefits Program: Competition and Other Factors
Linked to Wide Variation in Health Care Prices GAO-05-856,” August 2005, available at http://www.gao.gov/
new.items/d05856.pdf.
15 J. White, R. Hurley and B. Strunk, “Getting Along or Going Along?” Center for Studying Health System Change,
January 2004.
16 R. Berenson, P. Ginsburg, and N. Kemper, “Unchecked Provider Clout In California Foreshadows Challenges To
Health Reform,” Health Affairs, vol. 29, no. 4.
17 Fallon Community Health Plan v. Division of Insurance, Docket No. R2010-07, August 6, 2010.
18 Office of Attorney General Martha Coakley, “Investigation of Health Care Cost Trends and Cost Drivers,” January
2010.
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Health care services and items in the United States generally lack unit price transparency because
they are considered proprietary contractual negotiations between payers and providers.19
Moreover, standard measures of producer price inflation, such as the PPI, are inappropriate to
examine the unit price inflation among privately insured persons because they include prices paid
by consumers that are uninsured or are in government programs (e.g., Medicare and Medicaid).
However, one survey by Segal Consulting found that the annual price inflation for hospitals has
increased from 7.7% to 8.5% between 2008 and 2011 (2011 estimates from insurers are based on
provider-contracted rates set before the coverage year begins).20 Annual price inflation decreased
from 4.0% to 3.1% for physicians during the same period, and prescription drug price inflation
stayed around 6.5% between 2008 and 2010 (drug price data were not available for 2011).
Health Service Utilization
The conventional wisdom has been that the aging of the American population is the primary or
major driver of increased demand for health services and prescriptions drugs experienced by
health insurers.21 On its face, this seems logical given that the elderly have the highest utilization
of health care.22 However, the overall age distribution of the population actually shifts very
slowly over time. Indeed, the median age of the U.S. population is projected to increase just 1.8
years, from 36.9 in 2010 to 38.7 in 2030.23 In terms of risk based on age, private health insurance
benefits from the Medicare program, which assumes the liability of coverage for most persons
over the age of 65. Ultimately, what matters for the insurer is not merely the general population
trends, but the specific age distribution of the risk pool being insured. Moreover, studies have
found that while aging does have an impact on rising health care utilization, other factors such as
advances in costly medical technology and medical practice patterns drive demand more.24
Without countervailing regulations, such as minimum loss ratios, health insurance companies
have a financial incentive to restrain utilization. Generally, the less they pay in health benefits, the
higher their profits will be. Health insurance companies can implement a number of different
management techniques or limitations on coverage to restrain health care utilization. Traditional
utilization management techniques include utilization review, case management, and physician
gatekeeping.25 Insurers may also attempt to limit the use of high-priced or high-utilizing health
19 Congressional Budget Office, “Increasing Transparency in the Pricing of Health Care Services and Pharmaceuticals,”
June 5, 2008.
20 Segal Consulting, “2011 Segal Health Plan Cost Trend Survey,” October 2010, available at http://www.segalco.com/
publications-and-resources/surveys-studies/?id=1519.
21 U. Reinhardt, “Does The Aging Of The Population Really Drive The Demand For Health Care?” Health Affairs,
2003, vol. 22, no. 6 (hereafter cited as “Aging”).
22 Steven Cohen and William Yu, “The Concentration and Persistence in the Level of Health Expenditures over Time:
Estimates for the U.S. Population, 2005–2006,” Agency for Healthcare Research and Quality, February 2009.
23 U.S. Census Bureau, National Population Projections Table 12. Projections of the Population by Age and Sex for the
United States: 2010 to 2050, 2008. Available at http://www.census.gov/population/www/projections/
summarytables.html.
24 See B. Strunk, P. Ginsburg, and M. Banker, “The Effect Of Population Aging On Future Hospital Demand,” Health
Affairs, Web Exclusive, vol. 25, no. 3; and “Aging.”
25 Utilization review includes prospective reviews, often called prior authorization (PA), that attempt to constrain health
care costs by reducing unnecessary or inappropriate medical care before the care takes place. For example, a plan might
conduct a preadmission review to certify the need for a hospitalization and assign an initial length of stay. Case
management includes care coordination and the use of evidenced based medicine to ensure the highest probability of
positive outcomes in a cost effective manner. For example, for a member with heart disease, a plan might coordinate
between a primary care physician and a cardiologist to ensure that there is no duplication in services, such as
(continued...)
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Private Health Insurance Premiums and Rate Reviews
care providers through their network contracting process. Since the cost sharing is lower for in-
network providers, the plan can financially incentivize its members to use lower-cost providers by
contracting only with them.26 Finally, insurers may choose to not cover a particular procedure, use
of a technology, or prescription drug.
Generally, utilization management techniques and restrictive benefits became prevalent in the late
1980s, but their use has been waning since the mid-1990s, in the face of strong consumer
resistance to anything other than case management, where coordination between providers and
evidence based medicine are used to improve outcomes.27 For example, in the employer group
market enrollment in health maintenance organizations (HMOs), the most restrictive type of plan,
dropped from 31% in 1996 to 19% in 2010, while less restrictive preferred provider organization
(PPO)/point of service (POS)28 plans increased from 42% to 66%.29 In the individual (non-group)
market, 2009 data from American’s Health Insurance Plans (AHIP) indicate that 82.8% of
members with single coverage and 72.9% with family coverage elect a PPO/POS plan, with less
than 2% electing HMO or similarly restrictive plans.30
As the market has moved away from health insurance products with strong utilization
management programs and limited provider networks, utilization of health services and
prescription drugs has consistently increased every year, as measured in population-based surveys
and gross sales figures.31 However, these trends in gross measures of service utilization could be
explained by increases in the total population or the number of persons that are insured. In other
words, per insured member service utilization may not be increasing. However, studies where
researchers have had access to claims data and provider payment rates have found that most of
the increase in health benefits expenditures, other than certain outpatient procedures and
prescription drugs, are attributable to increases in unit prices not to increases in the utilization per
insured member.32
(...continued)
prescribing the same drug twice. Physician gatekeeping means requiring that a plan member get a referral from a
primary care physician before being able to see a higher-cost specialist. For more information on utilization
management, see T. Wickizer and D. Lessler, “Utilization Management: Issues, Effects, and Future Prospects,” Annual
Review of Public Health, 2002, vol. 23.
26 J. Zwanziger and G. Melnick, “Can Managed Care Plans Control Health Care Costs?” Health Affairs, Summer 1996,
vol. 15, no. 2.
27 CRS Report R40834, The Market Structure of the Health Insurance Industry, by D. Andrew Austin and Thomas L.
Hungerford.
28 Generally speaking, enrollees in PPO and POS plans have more choice of providers in that they can go out-of-
network (OON) and pay more cost sharing than they would for an in-network provider. By contract, HMO enrollees
generally would have to pay all or substantially all of the cost for OON services.
29 The Kaiser Family Foundation, “Employer Health Benefits 2010 Annual Survey,” September 2010.
30 America’s Health Insurance Plans, “Individual Health Insurance 2009: A Comprehensive Survey of Premiums,
Availability, and Benefits,” October 2009.
31 For example, see Susan M. Schappert and Elizabeth A. Rechtsteiner, “Ambulatory Medical Care Utilization
Estimates for 2006,” August 2008, available at http://www.cdc.gov/nchs/data/nhsr/nhsr008.pdf; Avalere and the
American Hospital Association, “Trends Affecting Hospitals and Health Systems,” 2010, available http://www.aha.org/
aha/research-and-trends/chartbook/ch3.html; and IMS Health, “Top Therapeutic Classes by U.S. Dispensed
Prescriptions,” April 2010, available at http://www.imshealth.com/.
32 Milliman, Inc., “2010 Milliman Medical Index,” May 2010, available at http://publications.milliman.com/
periodicals/mmi/pdfs/milliman-medical-index-2010.pdf; T. Reuters, “Trends in Spending for Physician Services
Among the Privately Insured, 2004 and 2008,” April 2010; M. Bundorf, A. Royalty, and L. Baker, “Health Care Cost
Growth Among The Privately Insured,” Health Affairs, vol. 28, no. 5; and L. Wier, R. Henke, and B. Friedman,
(continued...)
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Administrative Costs
In addition to paying for medical claims, premiums are expected to cover the operational costs of
the insurance company. Health insurance companies generally are complex organizations
requiring specialized human resources and information technology to perform the functions of
developing, marketing, and operating a health plan or insurance policy. Table 2 provides a
summary review of administrative functions in health insurance plans.
Insurance company-reported PMPM administrative costs in regulatory filings indicate a relatively
stable trend, with average costs per company increasing only about $3 PMPM from 2007 to 2009
(Figure 4). Variation between companies was observed, with specialty companies (e.g., dental
only, behavioral health) generally reporting below $10 of PMPM in administrative costs, and
companies with an emphasis on non-group insurance often reporting more than $100 PMPM in
administrative costs. Administrative expenses have been found to vary by market segment, with
non-group insurance costing the highest and large group the lowest.33 This is attributable to
factors such as enrollment size (non-group enrollment typically is smaller, thus there are fewer
persons to spread the costs around to). While group plans can sell to a few individuals (usually an
employer’s human resources department), non-group insurance must be sold one-by-one to each
person, thus increase marketing and sales costs.
Table 2. Summary of Health Insurance Administrative Functions
Account and Member
Provider & Medical
Administration
Corporate Services
Marketing and Sales
Management
Claims processing
Finance and accounting
Market research
Provider contracting
Member enrollment
Actuarial
Advertising
Utilization management
Customer service
Risk management
Sales to employer groups
Quality improvement
Information technology
Legal and compliance
Sales to individuals
Wellness programs
Member communications
Executives/management
Promotions
Pharmacy management
Account management
Governance (Board)
Underwriting
Provider services
Source: Adapted from the work of Sherlock Company on administrative costs in health plans, available at
http://www.sherlockco.com/.
(...continued)
“Diagnostic Groups with Rapidly Increasing Costs, by Payer, 2001–2007,” June 2010, available at http://www.hcup-
us.ahrq.gov/reports/statbriefs/sb91.jsp.
33 Douglas Sherlock, “Administrative Expenses of Health Plans,” 2009.
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Figure 3.Average Health Insurer Administrative Costs Per Company, 2007-2009
Per Member Per Month
$32.00
3.91% change
from 2008
$30.00
6.77% change
from 2007
$28.00
$30.30
$29.16
$26.00
$27.31
$24.00
CY2007
CY2008
CY2009
Source: HighlineData’s Insurance Analyst Pro database of health insurer regulatory filings.
Notes: Includes 673 different legal entities reporting in all three years with at least 1,000 enrollees. Legal entities
with less than 1,000 enrollees were excluded because they typically were startup companies with outlier cost
structures. A legal entity refers to an incorporated business licensed to sell insurance. Many large corporate
parent organization have multiple legal entities. For example, Aetna has 16 different companies within this
dataset.
A company with multiple products generally prices each product separately. For example, Ford
Motor Company does not have one price for each of its vehicles. It charges separate prices for the
Explorer, Taurus, Fusion Hybrid, and its other models. Similarly, premium rates are calculated at
the health insurance product level (i.e., the health plan or policy that a person, family, or
employer purchases), not at the company or corporate parent levels (i.e., the corporate entity that
sells the insurance product).34 So additional variation might be observed within each company if
product level data were available.
These data are also limited by the fact that many health insurance companies have multiple non-
insurance businesses. For example, the United Health Group (UHG) includes the information
technology and consulting firm Ingenix and the pharmacy benefits manager (PBM) Prescription
Solutions in addition to its health insurance benefits business segment.35 The inherent complexity
of a large conglomerate may create unique challenges for accurate cost accounting down to the
individual plans and insurance products sold within the organization. These challenges could
create barriers to fair and comprehensive regulation of administrative costs across different types
34 For example, United Health Group is the corporate parent of Golden Rule Insurance Company, which sells several
different individual insurance policy products each with their own premium rate calculations. For more information,
see Golden Rule Insurance Company, “UnitedHealthOneSM Personal Health Insurance Plans for Individuals and
Families,” 2010, available at https://www.uhone.com/FileHandler.ashx?FileName=38960LC8-G201008.pdf.
35 Ingenix itself is a conglomerate that includes the health policy firm the Lewin Group and the actuarial consulting
firm Reden & Anders. For more information, see United Health Group “Annual Report for the Fiscal Year Ended
December 31, 2009,” Form 10-K filing with the Securities and Exchange Commission, available at
http://www.unitedhealthgroup.com/invest/2009/UNH-2009-10-K.pdf.
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of health insurance companies (i.e., small local and regional non-profit insurers versus large
national investor-owned, for-profit insurers).
There is no consensus benchmark for what is an appropriate amount of administrative costs.
Nevertheless, several industry executives of the publicly traded for-profit firms believe that
administrative costs can come down as evidenced in the summary of recent earnings conference
calls provided in Table 3.
Table 3. Quotes from Health Insurance Executives About Administrative Costs
Executive’s Name and
Organization
Quotes Concerning Administrative Costs
Allen Wise, CEO of
During 2009, we spent time addressing the administrative cost structure for these
Coventry Health Care
areas and improvement will continue during 2010. While I can’t predict where
changes in government involvement will go there are certain things we can and
must do everyday. We can better manage our cost structure and we wil . This
includes both medical and [selling, general, and administrative (SG&A) expenses].
Michael McCallister, CEO
Administrative cost savings is another important enterprise wide initiative that
of Humana
positions us favorably for the future across al our businesses. On the whole we’re
taking a deliberate strategic long-term approach to creating the efficient and agile
infrastructure we’ll need to position us wel for the future.
Michael Neidorff,
Further [general and administrative (G&A) expense] reduction beyond 2010
Chairman, President, and
remains a top priority, and our ongoing systems investments should enable us to
CEO of Centene
accomplish this goal.
Corporation
Wayne DeVeydt, Executive
I do think overall SG&A, you’re going to see come down in absolute dollars. Not
Vice President & Chief
just because of the PBM going away, but we needed to right-size our organization
Financial Officer of
relative to our membership. So those will be things that we will talk out about
Wellpoint Inc.
separately, but in general, I don’t think you’re going to see SG&A be elevated. It’s
going to be just the opposite impact.
Ronald Williams, CEO of
As we go forward in 2011, we understand the need to bring our SG&A down.
Aetna
Sources: Allen Wise, “Coventry 4th Quarter 2009 Earnings Call,” February 9, 2010, available at
http://seekingalpha.com/article/187560-coventry-health-care-inc-q4-2009-earnings-call-transcript?page=-1&find=
coventry. Michael McCallister, “Humana 4th Quarter 2009 Earnings Call,” February 1, 2010, available at
http://seekingalpha.com/article/185811-humana-inc-q4-2009-earnings-call-transcript?page=-1&find=humana.
Michael Neidorff, “Centene 4th Quarter 2009 Earnings Call,” February 9, 2010, available at
http://seekingalpha.com/article/187587-centene-corporation-q4-2009-earnings-call-transcript?page=-1. Wayne
DeVeydt, “Wellpoint 4th Quarter Earnings Call,” January 27, 2010, available at http://seekingalpha.com/article/
184862-wellpoint-inc-q4-2009-earnings-call-transcript?page=-1. Ronald Williams, “Aetna 2nd Quarter 2010
Earnings Call,” July 29, 2010, available at http://seekingalpha.com/article/217209-aetna-q2-2010-earnings-call-
transcript.
Note: The term “S,G,&A” means selling, general, and administrative and is reported on the income statement, it
is the sum of all direct and indirect selling expenses and all general and administrative expenses of a company.
Health Insurance Company Profits
There is substantial variation in health insurance company profits due to differences in the size of
the companies and their willingness to aggressively manage health costs. Wellpoint, a large
(33.67 million members) investor-owned, national for-profit company, emphasizes reduced costs
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Private Health Insurance Premiums and Rate Reviews
and value for its investors. 36 In 2009, Wellpoint had $4.75 billion in net income (profits after
taxes). By contrast, Blue Cross Blue Shield of Rhode Island (BCBS-RI), a mid-sized (447,000
members) non-profit company operating in one state with a community mission, took nearly a
$99.9 million loss in 2009.37 Weiss Ratings found that the average profit margin (net income
divided by revenues) in 2009 of the 543 health insurers studied was 2.6%.38 Profit margins were
higher (9.9% vs. the 2.6% average) for large companies ($1 billion or more in assets) with low
medical costs in relation to premiums (a medical loss ratio below 85%), as illustrated by Figure
4.39 Because of the membership scale associated with more profitable health insurers, it is
unlikely that reductions in net income would have a substantive impact on premiums for
individual members. For example, if Wellpoint’s entire 2009 net income of $4.75 billion were
rebated back to its 2009 members, it would result in a monthly premium credit of $11.75.40
Figure 4. Health Insurance Company Profit Margins, 2009
Stratified by Company Size and Medical Loss Ratio (MLR)
12.0%
9.9%
10.0%
8.0%
6.0%
4.5%
4.0%
2.0%
0.9%
0.6%
0.0%
Large < 85%
Small < 85%
Large > 85%
Small > 85%
MLR
MLR
MLR
MLR
Source: Weiss Ratings, “Health care reform could cost health insurers far more than expected,” August 2010.
Notes: Large companies are defined as those with $1 billion or more in assets. A medical loss ratio (MLR) is the
percentage of premium revenues spent on medical claims. It is a common metric assessing the ability of a health
insurance company to manage health costs. The Patient Protection and Affordable Care Act (P.L. 111-148,
PPACA) establishes 85% as a minimum MLR for large group plans.
36 Wellpoint, 2009 Summary Annual Report,” April 2010.
37 Blue Cross Blue Shield of Rhode Island, “2009 Annual Report,” March 2010.
38 Weiss Ratings, “Health care reform could cost health insurers far more than expected,” August 2010.
39 A medical loss ratio (MLR) is the percentage of premium revenues spent on medical claims. It is a common metric
assessing the ability of a health insurance company to manage health costs. The Patient Protection and Affordable Care
Act (P.L. 111-148, PPACA) establishes 85% as a minimum MLR for large group plans.
40 Net income in 2009 of $4,745,900,000 divided by 2009 membership of 33,670,000 equals $140.95 (rounded) divided
by 12 months equals $11.75 (rounded) per member per month.
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The Underwriting Cycle
The health insurance underwriting cycle refers to the tendency for health insurance premiums and
insurer profitability to cycle over certain time intervals.41 (This is a different, but related, concept
to medical underwriting, which is the process by which an insurer estimates the insurance risks
and potential medical costs associated with an applicant for insurance based on characteristics of
that applicant.) Upturns and downturns in the underwriting cycle are basically the outcome of
adjustments to premiums that reflect past experience, expectations of future losses, business
strategy, attempts to mitigate possible impacts of regulatory changes, and the changing consumer
demands of the members and policyholders (e.g., demand for large and open provider networks).
For example, a health insurance company may charge premiums above the anticipated amount
necessary for the current plan year’s costs because the insurer lost money on the product in
previous years. This will start an up cycle in profitability until it prices itself out of the
competitive market, thus forcing a cut in premiums and ultimately profit margins. Alternatively,
the insurer may have a business strategy to obtain as much market share as possible. To do this,
the insurer reduces premiums below competitors, even if it reduces profit margins or results in a
temporary loss. Once the insurer commands the desired market share, it increases premiums to
achieve the desired maximum profit margin that the market will allow.
Adding to the complexity, the insurance company often may attempt to subsidize one policy or
plan with profits from another. To illustrate this, Table 4 provides an example of one insurance
carrier’s actual premium and medical loss experience in one state between 2007 and 2009. The
table was abstracted from a premium rate increase request for 2010 for individual market blocks
of business with and without maternity coverage from Anthem Blue Cross Life and Health
Insurance Company (hereafter referred to as “Anthem”) submitted to the California Department
of Insurance. For the years 2007 through 2009, the table presents the actual per member per
month (PMPM) premiums charged, the PMPM claims experience, the medical loss ratio (the
percentage of premiums spent on medical claims), the total member months, and the gain or loss
on medical expenses by the maternity and non-maternity blocks of business in the individual
(non-group) market. Member months are used to reflect enrollment based metrics because
individuals can join or leave a plan or policy on a monthly basis. Thus, having a member for 6
months versus the full year (12 member months) would be meaningful in terms of total premiums
collected and likely claims experience.
Anthem’s maternity coverage policies had an operational gain in 2007, with relatively few
policyholders (in member months). However, these policies operated at a loss in 2008 and 2009
despite a higher number of policyholders. Based on this trend, Anthem projected nearly a $14.2
million loss for 2010 on the maternity block of business. What are some of the options for
Anthem or any other insurance company in a situation like this? It could increase premiums in the
maternity coverage policies to $320 PMPM to match expected claims costs PMPM for 2010, but
that would be nearly a 74% increase from premiums in 2009. Alternatively, Anthem could
eliminate the maternity coverage policies, seek out non-premium sources of revenue (e.g.,
investment income), aggressively implement managed care methods to reduce costs, or make up
for the losses in this product with gains from another product line.42 The latter option is what
41 See Alice Rosenblatt, “The Underwriting Cycle: The Rule Of Six,” Health Affairs, vol. 23, no. 6; and R. Kipp, J.
Cookson, and L. Mattie, “Health Insurance Underwriting Cycle Effect on Health Plan Premiums and Profitability,”
April 10, 2003.
42 Investment income refers to income received from investment assets (before taxes) such as bonds, stocks, mutual
(continued...)
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Anthem suggests in this rate filing. In other words, losses from the maternity coverage are
financially cancelled out for the company by gains from the policies sold without maternity
coverage.
Table 4. Anthem Individual Health Insurance Rates for Policies in California
With or Without Maternity Coverage
Actual or
Premium
Claims
Medical
Member Gain/Loss on
Coverage projected
Year
PMPM
PMPM Loss Ratio
Months
Medical Expenses
Actual 2007
$179
$108
60%
12,141
$862,011.00
Actual 2008
$184
$217
118%
64,348
-$2,123,484.00
Maternity
Coverage Actual 2009
$184
$268
146%
105,490
-$8,861,160.00
Projected 2010
$195
$320 164%
113,340
-$14,167,500.00
Actual 2007
$116
$309
266%
89
-$17,177.00
No
Actual 2008
$130
$66
51%
61,271
$3,921,344.00
Maternity
Coverage Actual 2009
$141
$86
61%
205,371
$11,295,405.00
Projected 2010
$154
$111 72%
329,486
$14,167,898.00
Source: Anthem Blue Cross Life and Health Insurance Company, “Rate for Individual Policies,” submitted to the
California Department of Insurance June 30, 2010, available at http://www.insurance.ca.gov/0250-insurers/
IndHlthRateFilings/upload/AnthemCHDPPF201002158.pdf.
Notes: The acronym PMPM stands for per member per month. The term “medical loss ratio” means the
percentage of premiums spent on medical claims. The term “member month” refers to each month of coverage
for an enrollee or policyholder, thus a member for a ful year would have 12 member months. Gain/Loss on
medical expenses refers to the gain or loss experienced from paying medical claims out of premium revenues.
This calculation does not involve other financial factors such as administrative costs.
Review of Health Insurance Rates
The regulation of private health insurance has traditionally been under the jurisdiction of the
states.43 Most states have used their regulatory authority over the business of insurance to require
the filing of health insurance documents containing rate information for one or more market
segments or plan types.44 With the enactment of the Patient Protection and Affordable Care Act
(P.L. 111-148, PPACA) on March 23, 2010, the federal government will assume a role in private
(...continued)
funds, loans and other investments (less related expenses).
43 For additional information about state and federal regulation of private health insurance, see CRS Report RL32237,
Health Insurance: A Primer, by Bernadette Fernandez.
44 CRS analysis of state law and regulations from a search of CyberRegs, available at http://www.cyberregs.com/. Also
see National Association of Insurance Commissioners, “NAIC Response to Request for Information Regarding Section
2794 of the Public Health Service Act,” May 12, 2010 (hereafter cited as “NAIC Response”). For the purposes of this
discussion, the District of Columbia is considered a state. Only Missouri, Montana, and Wyoming have no filing
requirements for individual and group plans. Three states (Alabama, Georgia, and Mississippi) require filings for
informational purposes only. The term “market segment” generally refers to individual, small group, and large group
markets. The term “plan type” generally refers to the way health benefits are provided and financed, such as through
indemnity insurance or preferred provider organizations.
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health insurance rate reviews by providing grant funding to states for rate reviews and requiring,
among other things, that plans and insurers justify certain rate increases.
State Rate Filing and Reviews
As the primary regulators of health insurance, states oversee many aspects of the industry
concerning the insurance products offered in the market and the entities that sell insurance. One
fundamental area in which states exercise regulatory authority is through the imposition of rate
and form filing requirements. “Form” refers to the language in the insurance contract and
typically is required when a new plan is offered in the market (or changes are made to that plan).
“Rate” refers to the price of a unit of insurance.45 Rates are filed with the initial form and usually
must be filed each time an insurance carrier proposes to change rates for a plan (or if changes in
the form filing affect rates).
Not all states actually conduct rate reviews. For those states that do, the purpose is threefold: to
ensure that rates are sufficient (to guard against insolvency), but not too high (must be actuarially
justified), nor unfairly discriminatory (variation in rates must be based on differences in expected
claims). There is substantive variation in state regulation of health insurance rates. Some states
collect rates for informational purposes only or as part of their form filing requirements. One state
has “use and file,” which means the filing becomes effective when used, though the insurer is
required to file rates with the state. A number of states have “file and use,” where the insurer must
file rates with the state, which become effective either immediately or on a date specified in the
filing. Under either of these scenarios, the state may disapprove a rate filing if it does not meet a
certain compliance standard, such as a minimum anticipated medical loss ratio. Over half of states
have “prior approval” requirements, where insurance companies must file proposed rate changes
and the state has the authority to approve, disapprove or modify the request. However, prior
approval authority typically also includes a deeming period; if the state does not take any action
and the deeming period elapses, the filing become effective. Under such a scenario, prior
approval requirements may effectively work just like file and use. (A list of rate filing
requirements by state is provided in Table 5.)
45 In any given state, the rate may vary according to the rating factors allowed by the state. For example, rates in the
individual market may be prohibited from varying based on health factors, but may be allowed to vary based on age,
sex, or other risk factors. The permissible variation in rates establishes theoretical parameters. The actual premiums
charged for a set of insurance policies may not span the spectrum of allowed rates; it depends on who applies and
accepts coverage.
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Table 5. State Rate Filing Requirements, by Market Segment, 2010
Use
No
File with
Information
and
File and
State
Requirement
Form
Only
File
Use Prior
Approval
Alabama
I,
S,
L
Alaska
I,
S,
L
Arizona S,
L
I
Arkansas S,
L
I
California
I,
S,
L
Colorado
I,
S,
L
Connecticut
I,
S,
L
Delaware
I,
S,
L
Florida
I,
S,
L
Georgia
I,
S,
L
Hawaii
I,
S,
L
Idaho S,
L
I
Illinois S,
L
I
Indiana
S,
L
I
Iowa
I,
S,
L
Kansas
I,
S,
L
Kentucky
I,
S,
L
Louisiana
I,
S,
L
Maine
I,
S,
La
Maryland
I,
S,
L
Massachusetts Sb, Lb
I
Michigan S,
L
I
Minnesota
I,
S,
L
Mississippi
I,
S,
L
Missouri I,
S,
L
Montana I,
S,
L
Nebraska
S,
L
I
Nevada S,
L
I
New
Hampshire
L
I,
S
New Jersey
Sc, Lc
I
New Mexico
I, S,L
New Yorkd
I,
S,
La 10/1/2010
forward
North
Carolina
I,
S,
L
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Private Health Insurance Premiums and Rate Reviews
Use
No
File with
Information
and
File and
State
Requirement
Form
Only
File
Use Prior
Approval
North Dakota
I, S, L
Ohio
I,
S,
L
Oklahoma
I,
S,
L
Oregon
L
I,
S
Pennsylvania
I,
S,
L
Rhode Island
I, S, L
South Carolina
S, L
I
South Dakota
S, L
I
Tennessee
I,
S,
L
Texas
I,
S,
L
Utah
I,
S,
L
Vermont
I,
S,
L
Virginia
S,
L
I
Washington
I,
S,
L
West Virginia
I, S, L
Wisconsin
I,
S,
L
Wyoming I,
S,
L
Washington
D.C.
I,
S,
L
Sources: National Association of Insurance Commissioners (NAIC), “State Rate Filing Requirements by Market
Segment ,” February 2009; National Association of Insurance Commissioners, “NAIC Response to Request for
Information Regarding Section 2794 of the Public Health Service Act,” May 12, 2010; and New York State, Office
of the Governor, “Governor Paterson Signs Landmark Health Insurance Reform Legislation,” June 9, 2010.
Notes: I – Individual Market. S – Smal Group Market. L – Large Group Market. “Form” refers to the language in
the insurance contract and typically is required when a new plan is offered in the market (or changes are made
to that plan). Rates are filed with the initial form and usually must be filed each time an insurance carrier
proposes to change rates for a plan, but the rates are generally not reviewed. “Informational” refers to rate filing
requirements where the data is collected and kept by the state, but is not reviewed. “Use and file” means the
filing becomes effective when used, though the insurer is required to file rates with the state, which may be
reviewed retrospectively. “File and use” refers to requirements where the insurer must file rates with the state,
which become effective either immediately or on a date specified in the filing. File and use state may review the
rates retrospectively after the effective date. In this case, states usual y base their review on claims and financial
data submitted by the insurer to examine if the rates were appropriate for the actual claims experience. “Prior
approval” refers to requirements where insurers must file rates with the state, and the state has the authority to
approve the filing or disapprove it before the effective date.
a. If insurer does not meet medical loss ratio standards, the rate filing is subjected to prior approval.
b. Insurers must still provide actuarial certification.
c. State imposes medical loss ratio requirements.
d. On May 9, 2010, then and now former New York Governor David A. Paterson signed into law Governor’s
Program Bill No. 278, which reinstates the New York State Insurance Department’s former authority to
review and approve health insurance premium increases before they take effect. The law applies to all rate
increases taking effect on or after October 1, 2010.
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Limits on publicly accessible rate review data make comprehensive uniform comparisons
between states elusive. Only 13 states have public Internet access to rate filings or summary
statistics on rates.46 Moreover, there is considerable variation in how states with rate review
regulations make their information public. For example, the Maine Bureau of Insurance posts rate
filings f only or insurers that are called to present their requested increase at a public hearing,
whereas the Oregon Insurance Division publicly provides a list of average rate increase requests
and approvals by regulated entities and provides access to individual rate filings and approvals.47
In terms of approvals of rate increases, there is considerable variation between states. For
example, Oregon approved 68.3% of recent requested rate increases, whereas Massachusetts
approved only 14.2%.48 These differences are likely due to both differences in regulatory
standards, geographic variation in health insurance markets, health services utilization patterns,
and health provider payment rates. The available public information suggests that states approve,
adjust, or reject requests for rate increases primarily based on an analysis of cost trends in relation
to rate increases approved in prior years, and that the approved rates can be double-digit
percentage increases from the previous year.49 To illustrate, consider the case of Regence Blue
Cross Blue Shield of Oregon, which requested an average annual increase of 26.4% for its
individual health plans but was approved for a 17.3% increase effective January 1, 2010.50
Despite medical costs increasing 12.6% from the prior year and a financial loss of 9.7%
($15,476,565) on these policies over the period of May 1, 2008, through April 30, 2009, Oregon
decided that the lower rate increase was appropriate because Regence had received an approved
average rate increase of 26.5% on the same policies for the previous year.51 By contrast, Health
Net Health Plan of Oregon’s individual health plans requested and received a significant average
annual rate increase of 22.8% effective on October 1, 2009.52 Oregon believed that the increase
was justified because Health Net lost money on these policies each year between 2005 and 2008
46 Those states are CO, CT, FL, IL, ME, NE, NJ, NC, OH, OR, PA, RI, and WI. See “NAIC Response.”
47 Maine Bureau of Insurance, “Filings,” May 14, 2010, available at http://www.maine.gov/pfr/insurance/filings/
filings.htm; and Oregon Insurance Division, “Summary of Recent Rate Request Decisions,” May 11, 2010, available at
http://insurance.oregon.gov/insurer/rates_forms/health_rate_filings/rate-request-summary.pdf. The Oregon Health Rate
Filings and Public Comments database is available at http://www4.cbs.state.or.us/ex/ins/filing/.
48 Oregon Insurance Division, “Summary of Recent Rate Request Decisions,” May 11, 2010, available at
http://insurance.oregon.gov/insurer/rates_forms/health_rate_filings/rate-request-summary.pdf; and Massachusetts
Office of Consumer Affairs and Business Regulation, Division of Insurance, “Patrick-Murray Administration’s
Division of Insurance Announces Decision on Rate Increase Submissions from Health Insurers,” April 1, 2010,
available at http://www.mass.gov/?pageID=ocapressrelease&L=1&L0=Home&sid=Eoca&b=pressrelease&f=
20100401_hirates&csid=Eoca.
49 CRS analysis of Colorado Department of Regulatory Agencies, “Annual Report of the Commission of Insurance to
the Colorado General Assembly on 2009 Health Insurance,” April 1, 2010; Florida Office of Insurance Regulation,
“Accident & Health Rate Change Summary 2010 Year to Date,” May 03, 2010; North Dakota Insurance Department,
“Blue Cross Blue Shield of North Dakota’s (BCBS) rate increases requested and approved since 2001,” April 9, 2010,
available at http://www.nd.gov/ndins/uploads/resources/583/bcbs-chart-web.pdf; Oregon Department of Consumer
Business and Services, “Health Insurance in Oregon,” January 2010; and Rhode Island Health Insurance
Commissioner, “Rate Factor Decisions Announced,” March 18, 2010, available at http://www.ohic.ri.gov/
2010%20RateFactorReview.php.
50 Oregon Insurance Division, “Rate Filing Decision Summary Regence BlueCross BlueShield of Oregon Individual
Health Insurance,” November 13, 2009, available at http://insurance.oregon.gov/insurer/rates_forms/
health_rate_filings/health-rate-filing-search.html.
51 Ibid.
52 Oregon Insurance Division, “Rate Filing Decision Summary Health Net Health Plan of Oregon, Inc. Individual
Health Plans,” July 24, 2009, available at http://insurance.oregon.gov/insurer/rates_forms/health_rate_filings/health-
rate-filing-search.html.
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(in aggregate $1,436,505) and it had received average rate increases less than the average increase
in medical costs for four of the past five years.53
Federal Reforms Affecting Premiums
The Patient Protection and Affordable Care Act (P.L. 111-148, PPACA) was signed into law on
March 23, 2010, and has since been amended. PPACA, as amended, has provisions designed to
bring down the cost of premiums through transparency in premium increases and minimum
medical loss ratio requirements, but it does not go as far as to include a formal prior approval
process for proposed rate increases. Specifically, the Health and Human Services (HHS)
Secretary must, in conjunction with the states, establish a process for the annual review of
unreasonable increases in premiums for health insurance coverage beginning in the 2010 plan
year.54 The term “unreasonable” is not defined by the law and presents a challenge in preventing
unintended consequences such as providing additional market leverage to large, national for-
profit companies over small, local non-profit insurers.55 The complexity of making such a
determination generally requires analysis of multiple factors by actuaries and accountants. Such a
review generally does not lend itself to the use of simplistic benchmarks such as merely
prohibiting double-digit percentage rate increases. As the National Association of Insurance
Commissioners (NAIC) notes:
The process should identify “potentially unreasonable” increases, with further review by
states and/or the HHS Secretary to determine any mitigating or exacerbating factors and
decide whether the increase is actually unreasonable. Any increase that is necessary to avoid
a future financial loss on the block of business is usually considered reasonable, unless there
are compelling reasons to determine that it is unreasonable. Rates that produce a financial
loss can affect consumers by impairing the financial soundness of the insurer, reducing the
insurer’s incentive to provide good customer service, reducing the insurer’s incentive to
continue providing coverage and shifting costs to other blocks of business.56
Health insurance issuers will be required to submit to the HHS Secretary, and the relevant state, a
justification for an unreasonable premium increase prior to implementation of the premium, and
the HHS Secretary will publicly disclose the information.57 The justification requirement does not
provide the HHS Secretary with the authority to prohibit the plan from implementing the rate
increase. In other words, this is a “sunshine” provision designed to publicly expose premium
53 Ibid.
54 §1003 PPACA: §2794(a) Public Health Service Act (PHSA). On April 14, 2010, the HHS Secretary issued a public
request for information on the provisions at §2794 PHSA including defining the term “unreasonable,” available at
http://edocket.access.gpo.gov/2010/2010-8600.htm.
55 Wall Street analysts at Credit Suisse stated that they “believe winners and losers will emerge in managed care.
Winners will have access to public-equity capital and invest strategically to offset margin compression by taking
market share from 1,200 insurers that may not survive.” See Investors’ Soapbox PM, “Healthy Picks in Managed Care:
Credit Suisse likes UnitedHealth Group, WellPoint, Coventry and Humana,” August 17, 2010.
56 See “NAIC Response.”
57 §1003 PPACA: §2794(a)(2) PHSA. Per §2791(b)(2) PHSA, the term “health insurance issuer” means an insurance
company, insurance service, or insurance organization (including a health maintenance organization) that is licensed to
engage in the business of insurance in a state and that is subject to state law which regulates insurance within the
meaning of section 514(b)(2) of the Employee Retirement Income Security Act of 1974. The term does not include a
group health plan, which includes self-insured plans. The term “self insured” refers to group benefits plans (usually
sponsored by employers) that take on the insurance risk, rather than contracting with an insurance company to take on
the insurance risk (fully insured plans).
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increases determined to be unreasonable. On December 23, 2010, the HHS Secretary issued a
notice of proposed rulemaking for the PPACA rate review provision, with a comment period
ending February 22, 2011.58 The HHS Secretary proposes that when the average increase, alone
or in combination with prior increases in the preceding 12-month period, is 10% or more then the
rates will be subject to more review to determine if they are unreasonable. The proposed
regulation stipulates that HHS would be adopting a state’s determination of what an unreasonable
rate increase is if the state has an effective rate review program. The proposed regulation specifies
that a state’s rate review program would be considered effective if the state has the legal authority
to obtain the data and documentation necessary to conduct an effective examination. Further, the
state must have the ability to review the data and documentation submitted in support of the
proposed rate increases, including an examination of the reasonableness of the actuarial
assumptions used by the insurer, the validity of historical data underlying the assumptions, and
the insurer’s accuracy with past projections. If the state does not have an effective rate review
program, the Secretary proposes that HHS would conduct the review. HHS would determine that
a rate increase is unreasonable if:
• The rate increase is excessive. The premium charged would be considered
excessive if it is unreasonably high in relation to the benefits provided. HHS
would consider if the rate increase results in a projected future loss ratio below
the medical loss ratio standard required under section 2718 of the PHSA . HHS
would also consider if any of the assumptions on which the rate increase is based
are not supported by evidence or do not support an increase of the magnitude
being proposed.
• The rate increase is unjustified. Health insurance issuers would be required to
provide certain data and documentation to HHS supporting the proposed rate
increase. If the data and documentation submitted are incomplete or inadequate
then the proposed increase would be determined to be unreasonable.
• The rate increase is unfairly discriminatory. A proposed rate increase would
be unfairly discriminatory if it results in premium differences within similar risk
categories that are not permissible under applicable state law or, if no state law
applies, do not reasonably correspond to differences in expected costs.59
To support the premium rate review process, PPACA requires the HHS Secretary to carry out a
program of grants to the states. These grants have an appropriation of $250 million for states to
use during the five-year period beginning with FY2010.60 On August 16, 2010, the HHS
Secretary announced the first award of $46 million to the 45 states and the District of Columbia
(DC) that had applied for grants. Each approved grantee will receive $1 million.61 While there
was some variation in the grant applications, all 46 approved grantees stated that they will require
health insurance companies to report more extensive and standardized information to better
evaluate proposed premium rate increases and 43 of the 46 grantees said they would make the
58 75 FR 81004-81029.
59 A “risk category” is a classification of a group of insured individuals who share a common characteristics, such as
age or geographic location, and are covered under a single insurance product.
60 §1003 PPACA: §2794(c) PHSA.
61 U.S. Department of Health and Human Services, “$46 Million in Grants to Help States Crack Down on
Unreasonable Health Insurance Premium Hikes,” August 16, 2010, available at http://www.hhs.gov/news/press/
2010pres/08/20100816a.html.
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new information publicly available in a consumer-friendly format.62 Several states (21 and DC)
indicated that they would use the grant money to help expand the scope of their current premium
rate review, such as moving to a prior approval process for proposed rate increases.63 Another 15
states indicated that they were seeking, and would need to obtain, additional authority under state
law before they could proceed with expanding the scope of their premium rate reviews.
In addition, PPACA enables and supports states’ creation by 2014 of “American Health Benefit
Exchanges” (hereafter referred to as exchanges), which are intended to be regulated marketplaces
for the purchase of health insurance.64 The HHS Secretary, in conjunction with the states, will
monitor premium increases of health insurance coverage offered through and outside of the
exchanges.65 States will make recommendations to the exchange in their state about whether a
health insurance issuer should be excluded from participation in the exchange based on a pattern
or practice of excessive or unjustified premium increases.66 The terms “pattern” and “practice”
are not defined by the law. PPACA also establishes that each exchange has the authority to
determine if making a certain health plan available “is in the interests of qualified individuals and
qualified employers” participating in such an exchange, but the exchange may not exclude a
health plan through the imposition of premium price controls.67
PPACA will also require a health insurance issuer offering group or individual health insurance
coverage (including a grandfathered health plan68) to meet a certain minimum medical loss ratio
(MLR).69 Minimum MLR requirements are designed to potentially restrain premium increases by
limiting the proportion of premiums that can be used for administrative expenses, including
profits, compared to medical expenses. Thus a plan cannot increase premiums while concurrently
reducing the amount spent on health benefits. On the other hand, minimum MLR requirements
may have a limited effect on restraining premium inflation if those premiums reflect increases in
administrative expenses and claims costs in proportion to the requirement.
Effective for plan years beginning on or after September 23, 2010, health insurance issuers in the
group and individual markets (including grandfathered health plans) are required to submit to the
HHS Secretary a report concerning the ratio of incurred loss (or incurred claims) to earned
premiums, typically referred to as an MLR.70 Beginning no later than January 1, 2011, PPACA
requires a health insurance issuer offering group or individual health insurance coverage
62 U.S. Department of Health and Human Services, “Health Insurance Premium Grants: Detailed State by State
Summary of Proposed Activities,” August 11, 2010, available at http://www.healthcare.gov/news/factsheets/
rateschart.html.
63 Ibid.
64 CRS Report R40942, Private Health Insurance Provisions in the Patient Protection and Affordable Care Act
(PPACA), by Hinda Chaikind, Bernadette Fernandez, and Mark Newsom.
65 §1003 PPACA: §2794(b) PHSA.
66 §1003 PPACA: §2794(b)(1)(B) PHSA.
67 §1311(e)(1)(B) PPACA.
68 The term “grandfathered plan” refers to a health plan or health insurance coverage which had at least one enrollee on
the date of PPACA enactment (March 23, 2010). For more information about grandfathered plans, see CRS Report
R41166, Grandfathered Health Plans Under the Patient Protection and Affordable Care Act (PPACA), by Bernadette
Fernandez.
69 This provision includes fully insured grandfathered plans.
70 §1001, as amended by §10101: §2718 PHSA. Beginning on January 1, 2014, this calculation will be based on the
averages of the premiums expended on the costs for each of the previous three years for the plan. The Secretary will
make these reports available to the public on the Internet site of the Department of Health and Human Services.
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(including grandfathered health plans) to provide an annual rebate to each enrollee on a pro rata
basis if the ratio of the amount of premium revenue expended by the issuer on clinical claims and
health quality costs, after accounting for taxes, regulatory fees, risk adjustment, risk corridors,
and reinsurance, is less than 85% in the large group market and 80% for the small group and
individual markets.71 States are permitted to adjust the percentage for the individual market if it is
determined that the application of the 80% minimum MLR would destabilize the market in the
state. On December 1, 2010, the HHS Secretary promulgated regulations establishing a process
whereby states may request an adjustment of the target MLR for the individual market if the
evidence suggests that there is a substantive risk that a large number of individuals would lose
their insurance or pay higher premiums and not have reasonable alternatives for coverage.72
HHS estimates that for insurance products that do not meet the MLR requirements in 2011, the
average rebates for a person insured for the full 12 months will be between $150-$164 for
individual policies, $216-$587 in small group plans, and $127-$312 in large group plans.73 But
for insurance products meeting the MLR standards, it is unclear what impact these standards will
have, if at all, on the premium rates.
71 §1001, as amended by §10101(f) of PPACA: §2718 PHSA. For an explanation of the risk adjustment, risk corridors,
and reinsurance provisions, see CRS Report R40942, Private Health Insurance Provisions in the Patient Protection
and Affordable Care Act (PPACA), by Hinda Chaikind, Bernadette Fernandez, and Mark Newsom.
72 75 FR 74864.
73 75 FR 74907-74909.
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Appendix. Private Health Insurance Cost-Sharing
Other Insurance Costs Not Included in the Premium
Health insurance premiums generally represent only a part of the insured individual or family’s
costs incurred under a given benefits plan for health services and prescription drugs. While
enrollees and policyholders pay premiums irrespective of health service use, they typically are
responsible for cost sharing in the form of deductibles, flat dollar co-payments, and/or percentage
co-insurance only when services are used.74 Increased cost sharing has been viewed by some as a
method of shifting costs to those who are utilizing the services, thus limiting the shared risk and
constraining premium growth.75 On the other hand, increasing cost-sharing reduces the value of
the coverage at the same time premiums are going up. Essentially individuals and families end up
paying more for less, due to exposure to higher out-of-pocket costs.
Similar to the observed increases in premiums, cost-sharing expenses have been increasing.76
Thus, some individuals may be able to afford purchasing the insurance, but not be able to afford
the cost of utilizing health care services despite being insured. From a consumer perspective,
deductibles have the most impact because coverage does not start until the enrollee spends more
than the deductible amount. As illustrated in Figure A-1, deductibles have been increasing across
plan types in both the group and non-group markets. Comprehensive data on other benefit designs
such as drug co-payments and hospital co-insurance are not publicly available. However, the
Milliman Medical Index estimates that for a typical family of four with private employer group
coverage, out-of-pocket cost sharing has increased between 5.4% and 10.5% annually between
2006 and 2010.77
74 The term “deductible” means a fixed dollar amount during the benefit period that an insured person pays before the
insurer starts to make payments for covered medical services. In other words, there is 100% cost sharing until the
deductible amount has been reached. (Though some plans may not apply certain services to the deductible requirement,
such as well-child visits, to not discourage the use of such services.) The term “flat dollar co-payments” means medical
cost sharing in a health insurance plan that requires an insured person to pay a fixed dollar amount when a medical
service is received. The insurer is responsible for the rest of the reimbursement. The term “percentage co-insurance”
means of medical cost sharing in a health insurance plan that requires an insured person to pay a stated percentage of
medical expenses after the deductible amount was paid. Thus is the co-insurance is 10% and the medical service is
$100 then the member or policyholder would pay $10.
75 T. Bodenheimer, “High and Rising Health Care Costs. Part 1: Seeking an Explanation,” Annals of Internal Medicine,
vol. 142, no. 10, 2010.
76 J. Gabel et al., “Trends in Underinsurance and the Affordability of Employer Coverage, 2004-2007,” Health Affairs,
Web Exclusive, vol. 28, no. 4.
77 Milliman Inc., “2010 Milliman Medical Index,” May 2010.
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Figure A-1. Average Deductibles, by Health Insurance Plan Type, CY2007-2009
$3,500
$3,128
$3,000
$2,760
$2,610
$2,500
$2,326
$2,084
$1,972
$1,838
$2,000
$1,812
$1,729
$1,500
$1,061
$1,000
$752
$699
$634
$621
$503
$560
$401
$461
$500
$0
Group HMO
Group PPO
Group POS
Group HDHP
Non-group
Non-group
individual
family
CY2007
CY2008
CY2009
Source: For group health plans, Kaiser/HRET Survey of Employer-Sponsored Health Benefits available at
http://ehbs.kff.org/. For non-group health plans, “The Cost and Benefits of Individual and Family Health Insurance
Plans 2009,” eHealthInsurance, December 2009.
Notes: CY means calendar year. HMO means a health maintenance organization. PPO means a preferred
provider plan. POS means a point of sale plan. HDHP means high deductible health plan.
Author Contact Information
Mark Newsom
Bernadette Fernandez
Specialist in Health Care Financing
Specialist in Health Care Financing
mnewsom@crs.loc.gov, 7-1686
bfernandez@crs.loc.gov, 7-0322
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