Benefit designs for high cost medical conditions

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By Bruce S. Pyenson, Kathryn V. Fitch | 17 May 2011

This paper provides an actuarial view of high cost patients and how their incurred medical costs are allocated between the health plan and the member. We present the cost burden high cost patients incur under less generous coverage as well as actuarially equivalent benefit design changes that can protect high cost patients. The authors chose to define high cost or catastrophic patients as those who incur over $100,000 in allowed medical claim costs in a year.

This paper was commissioned by Genentech, Inc.