PBM Best Practices Series: What to expect from your PBM account team
Pharmacy benefit managers play a key role in helping plan sponsors manage prescription drug spend, and good account management can make all the difference
Among the key rating classifications for Medicare Supplement (MedSupp) business is attained age-based rate adjustments as reflected in the premium rate schedule.1 However, this classification can become neglected as a key component of rate structure alignment and an area of opportunity for new market entrants as well as existing carriers. This article delves into the theoretical actuarial considerations and the areas of opportunity in the market today.
Historical claims data, not to mention general rationale, support the understanding that medical claims generally increase with age.2 However, the rate of increase varies from one age to another as well as the underlying benefit structure (i.e., plan option). Each of the 11 standardized plan options is unique in the underlying coverage it provides beneficiaries as a result of the various Medicare out-of-pocket obligations in the form of deductibles, copays, and coinsurance.3 The change in claim cost by age (referred to as age slope or “slope” in this paper) for total allowed charges will be different from the slope for MedSupp Plans due to “deductible leveraging,” a concept explained in the example below.
Assume that the underlying medical benefit claim cost per member per month (PMPM) is expected to increase from $100 at age 70 to $105 at age 71, a 5% increase. However, if a fixed deductible of $10 PMPM (assumed claim cost value for both ages) is introduced, the benefit change increases from $90 ($100 - $10) to $95 ($105 - $10), a higher increase of 5.6%. The introduction of a deductible serves to steepen the slope. The greater the proportional value of the deductible, the greater the leveraging impact.
Based on this deductible leveraging concept, this paper focuses on Plan G and high-deductible Plan F as two primary examples, with the potential implications for the market today.4
Continuing the discussion of slope with a focus on Plan G, Plan F, and high-deductible Plan F (Plan HDF) practical applications, Figure 1 provides an example of expected claim cost slopes relative to age 65 for Plan F, Plan HDF, and Plan G for two sample ages relative to age 65 (1.000).5 The charts in Figures 2 and 3 provide a visual representation to get a sense of true differences. Note that slopes to other ages may not necessarily be linear and that, in practice, this evaluation and/or analysis would consist of multiple key ages.
Figure 1: Expected Claim Cost Slopes
|Age||Plan F||Plan HDF||Plan G|
Figure 2: Expected Claim Cost Slopes
Figure 3: Expected Claim Cost Slopes
These charts show the impact and relative significance of deductible leveraging of these different plan designs. The Plan G slope reflects a $185 Part B deductible while the Plan HDF slope is reflective of an upfront $2,300 deductible.
A rate schedule with age slopes consistent with the expected claim slopes has advantages such as the following:
Leading carriers in the market may use uniform rate slopes across all plans. However, it is rare to find Plan HDF rate slopes close to the expectations of claim costs for that plan. The rate slope approach typically used in the market provides opportunities for new market entrants as well as considerations for existing MedSupp carriers:
Other considerations and specific processes dealing with regulatory considerations are beyond the scope of this article.
Whether you are a new entrant in the product development stage or an established carrier evaluating plan performance and alternatives, a diligent management strategy should include recognition of the rate slope when compared against the market and expected claim levels.
This information is presented for demonstration purposes only.
Guidelines issued by the American Academy of Actuaries require actuaries to include their professional qualifications in actuarial communications. I, Kenneth L. Clark, am a consulting actuary for Milliman, Inc. and am a member of the American Academy of Actuaries. I meet the qualification standards of the American Academy of Actuaries to render the analysis contained herein.
The opinions expressed in this article are those of the author alone and do not necessarily reflect the opinions of Milliman or other employees of Milliman.