Actuarial Services
Designing strategies to help purchasers identify, quantify, and balance the risk associated with health care reform. CBIZ Optumas works with clients across the country and throughout the health care industry to both public and private payers.
The Future is Now
Technology is a powerful catalyst for creating business value. At CBIZ Optumas, we specialize in harnessing innovative actuarial solutions to elevate your business.
Actuarial Services
The team at CBIZ Optumas has over 65 years of experience developing actuarially certified rates for both public and private payers. We have developed actuarially sound rates for the following types of populations:
- Medicaid programs (Temporary Assistance for Needy Families, Aged/Blind/Disabled, General Assistance)
- Children’s Health Insurance Programs (CHIP)
- Medicaid expansion programs
- Large employer groups
- Provider groups
- Health Care Reform programs
These rates can cover all types of services (acute, ambulatory, long-term care, behavioral health, dental, pharmacy) for various types of managed care contractors (HMO, EPO, PPO). Our proven process includes requesting and analyzing data, calculating impact of programmatic changes, deriving trend assumptions, and building estimates for non-medical costs (administration, profit, risk and contingencies).
Our actuaries utilize CMS’s rate development checklist in developing all rates/premiums as well as any applicable actuarial standards of practice and state laws. We also provide an actuarial certification documenting our methodology and final rate ranges that comply with CMS’s requirements for Medicaid and expansion programs.
The selection and implementation of a risk adjustment payment methodology must be done in an actuarially sound manner. The over-arching principle of risk-adjusted capitation rating is to better match payment to risk. Practically, what this means is that health plans’ capitation payments would be adjusted to reflect the relative health risk burden of their enrollees, while the total capitation payments across all health plans would remain budget neutral.
Risk adjustment payment methodologies allow the capitation to be divided up among health plans differently than traditional capitation rates (e.g., set by geographic area, age, gender, program, and rating class).
The Optumas team has worked with diagnoses-driven, questionaires-driven, and pharmacy-driven risk adjustment tools. All have their strengths and weaknesses and we have helped our clients understand these and use them to their advantage. For example, we have tied diagnoses-driven tool implementations with pay-for-performance incentive programs that utilize the same diagnosis data coupled with recognized best practices for certain diagnoses.
Part of our process includes a review to ensure that the risk adjustment payment methodology and capitation rate range development are working appropriately together.
The actuarial team at CBIZ Optumas works with clients to determine the best plan design for their program goals. We calculate insurance premiums that are built on specific plan designs and specific populations. We have built an automated model that calculates the premium when various changes are made to the plan design, for example:
- Benefits switching from being covered to non-covered or vice versa (in whole or in part),
- Cost sharing (copayments, coinsurance) is increased or decreased,
- Overall benefit structure (deductible, out-of-pocket maximums) is adjusted,
- or Plan management (HMO, PPO, EPO) is changed.
The CBIZ Optumas team calculates the impact of programmatic changes on budgets and premiums. These programmatic changes can impact
- The population (i.e., who will enroll and show up for services due to the change?),
- The benefits (i.e., what types of benefits will enrollees receive?), and
- The reimbursement (i.e., mandating use of certain fee schedule as the floor).
We work closely with our clients to understand the programmatic change in order to determine all of the impacts on all of the various programs since there are typically ripple effects of the change. For example, increasing pharmacy benefit coverage for a particular program will typically bring in additional enrollees who are riskier than those originally enrolled.
Let’s Connect
Our team is here to help. Whether you’re looking for business solutions, financial strategies, or industry insights, we’re ready to collaborate. Fill out the form, and we’ll be in touch soon.