Healthcare cost modeling

Health Cost Guidelines Suite

Model healthcare utilization and expected claim cost with Milliman’s Health Cost Guidelines, the industry gold standard used by healthcare organizations worldwide.

Milliman Health Cost Guidelines Suite

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Overview

The industry gold standard

Incorporating more than 60 years of research and consulting, the Milliman Health Cost Guidelines are compiled from published, unpublished, private, and public data sources. Today, risk-bearing entities rely on our proprietary methodologies and comprehensive data to:

Model healthcare utilization for medical, pharmacy, or dental
Estimate claim costs and premium rates
Adjust national average healthcare costs for specific geographic areas, benefits, reimbursement structures, and plan characteristics

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HEALTH COST GUIDELINES FEATURES

Everything you need to evaluate pricing

In addition to being comprehensive, the Guidelines are flexible enough to accommodate your specific situation. Whether the focus is on a single benefit area, such as prescription drugs, or redesigning an entire benefit plan, the Guidelines will keep you up to date on the issues that affect your bottom line.

Always on time

The Health Cost Guidelines are updated annually to address the latest trends and regulatory compliance issues.

Exactly what you need

Milliman uses multiple sources of public and private data sources to produce the most comprehensive Health Cost Guidelines available.

We walk in your shoes

The products we sell are the tools we use. As the premier healthcare management consulting firm, Milliman uses the Health Cost Guidelines and underlying data daily to give our in-house actuarial consultants longitudinal insight into the key drivers of healthcare costs and utilization.

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Commercial

The Health Cost Guidelines–Commercial include the Commercial Rating Structures, Commercial Area Factors, Commercial Claim Probability Distributions, Managed Care Rating Model (MCRM), and Prescription Drug Rating Model (RxRM).

The Rating Structures are used to determine utilization, charge levels, and claim costs for various health benefits. The Area Factors are used with the Rating Structures to geographically adjust national average costs. Claims Probability Distributions help assess value of deductibles, out-of-pocket maximums, and the effect of plan maximums and area factors by deductible level. The two rating models automate the input and calculation of many of the rating variables and worksheets described in the managed care and prescription drug rating structures.

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Ages 65 and Over

The Health Cost Guidelines—Ages 65 and Over are used to adjust national average costs to specific geographic areas and to rate Medicare Advantage, Medicare Supplement, and retiree medical plans. They provide a basis for calculating prescription drug claim costs and allow for modifying costs based on age/gender mix, geographic area, trends, and other rating factors.

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Dental

The Dental Cost Guidelines allow you to:

Evaluate utilization, average charges, and cost sharing for a variety of plan designs
Access pricing details specific to orthodontia
Reflect a fee schedule adjusted by dental procedure code
Evaluate many cost-sharing alternatives or benefit-specific limits
Simplify claim cost development and enhance plan rating

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Reinsurance

Anticipate future claim levels, evaluate historical data, and establish relationships between health coverage levels using the Milliman Health Cost Guidelines—Reinsurance. These guidelines contain rating structures for reinsurance used with fee-for-service or managed care plans provided to commercial or Medicare enrollees.

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Grouper

Analyze and benchmark utilization and costs using the Health Cost Guidelines—Grouper, software which sorts medical and pharmacy claims data into hospital, surgical, medical, and other benefit service categories using Health Cost Guidelines (HCG) definitions.

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Prescription Drug Rating Manual

Determine claim costs for a wide variety of prescription drug benefit plans for either commercial, Medicare or retiree populations. The rating manual allows you to:

Quickly rate a multitude of benefit plan options
Estimate the cost of including some form of prescription drug coverage for Medicare-eligible beneficiaries
Estimate a wide variety of benefit design and pharmacy cost-management programs

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Milliman Medical Underwriting Guidelines

The Individual and Small Group Medical Underwriting Guidelines (MUGs) are evidence-based tools for underwriters to assess relative risk based on applicants’ medical and prescription drug histories, helping to determine coverage costs. Key features include:

Ratings for 1,400+ medical conditions, considering condition-specific factors
Prescription drug index of 4,000+ medications, with dosage patterns, discounts, and compliance rates
Drug/condition conversion tables for easy identification
Debit point distributions for actuarial calculations
Regular updates for technology, practices, and prescription drugs
Tailored guidelines for small group underwriting and rating

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Accelerate underwriting with Milliman WebMUGs

Streamline condition and rating searches, accelerate quotes, and enhance accuracy with web-based Medical Underwriting Guidelines (WebMUGs). Traditional manual underwriting processes can be error-prone and may lack the precision for accurate predictions. WebMUGs offers an easily searchable MUGs manual, eliminating the need to flip through physical documents. With WebMUGs, actuaries and underwriters can concentrate on higher-value tasks and refine underwriting using up-to-date data.