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6.6.5036    CALCULATION OF BENEFIT VALUES

(1) For the purposes of determining whether a health benefit plan is a basic health benefit plan under ARM 6.6.5032, a benefit value method may be developed and used by the small employer carrier as contemplated in 33-22-1803 (6) , MCA. The carrier has the option to use the following computations, together with the values listed, to determine a benefit value for major medical health insurance plans. This calculation may not be used for HMO health benefit plans. The values in Table I in (1) (d) of this rule may not be used for any health benefit plans with only partial medical coverage, such as hospital-only expense plans or hospital and surgical expense plans. The calculation and its result are subject to review and approval by the commissioner.

(a) An optional formula for calculating the benefit value is as follows:

BENEFIT VALUE = DEDUCTIBLE VALUE + COINSURANCE VALUE +

where

DEDUCTIBLE VALUE = DEDUCTIBLE CLAIMS COST x Y x

UTILIZATION (Y) / 0.8

and

COINSURANCE VALUE = COINSURANCE-STOPLOSS-PLUS-DEDUCTIBLE

CLAIMS COST x ([Z x UTILIZATION(Z) ] -

[Y x UTILIZATION(Y) ]}  / 0.8.

(b) The variables for the formula are defined as follows:

(i) COINSURANCE STOPLOSS refers to the maximum amount of annual claims to which the coinsurance is applied. For the standard plan, the COINSURANCE STOPLOSS is \$5,000.

(ii) DEDUCTIBLE CLAIMS COST is the expected claims cost for a plan with a particular deductible.

(iii) COINSURANCE-STOPLOSS-PLUS-DEDUCTIBLE CLAIMS COST is the expected claim cost for a plan with a "deductible" equal to the amount of the COINSURANCE STOPLOSS plus the DEDUCTIBLE.

(iv) LIFETIME MAXIMUM VALUE is the dollar adjustment to the expected claims cost for a particular lifetime maximum amount.

(v) UTILIZATION(Y) and UTILIZATION(Z) each refer to a factor to apply to the expected claims cost to adjust for expected utilization of a plan with a coinsurance level Y or Z.

(vi) Y is the coinsurance percent applied to claims, up to the amount of the coinsurance stoploss annually.

(vii) Z is the coinsurance percent applied to claims

above the coinsurance stoploss (usually 100%) .

(c) The following calculation of the benefit value

may be used:

(i) Determine the deductible claims cost.

(Table I)                                                                                                                     ____

(ii) Determine the value of Y, as a decimal.

(coinsurance percentage)                                                                                       ____

(iii) Determine the value of utilization(Y) .

(Table II)                                                                                                                    ____

(iv) Determine Y x utilization(Y) .

(line [ii] x line [iii])                                                                                                      ____

(v) Determine the deductible value.

(line [i] x line [iv] /0.8)                                                                                                ____

(vi) Determine the coinsurance-stoploss-plus-

deductible. (Coinsurance stoploss amount

+ deductible amount.)                                                                                              ____

(vii) Determine the coinsurance-stoploss-plus-

deductible claims cost. (Interpolate the claims

costs in Table I corresponding to the

deductibles immediately bounding the

coinsurance-stoploss-plus deductible.)                                                                 ____

(viii) Determine the value of Z, as a decimal.

(usually, but not always, 1.0)                                                                                    ____

(ix) Determine the value of utilization(Z) .

(Table II)                                                                                                                     ____

(x) Determine Z x utilization(Z) .

(line [viii] x line [ix])                                                                                                    ____

(xi) Determine the coinsurance value.

(line [vii] x(line [x] - line [iv]/0.8)                                                                                ____

value. (Table III)                                                                                                         ____

(xiii) Determine the benefit value.

(line [v] + line [xi] + line [xii])                                                                                     ____

(d) The following tables, or other tables with actuarially sound values, may be used in calculating benefit values under this rule:

Table I - Claim Costs by Deductible Amount *

 Deductible Amount Claims Cost Deductible Amount Claims Cost Deductible Amount Claims Cost \$    0 \$124.83 \$  750 \$ 89.29 \$ 10,000 \$ 24.92 100 119.43 1,000 79.77 15,000 20.56 150 116.82 1,500 68.70 20,000 17.38 200 114.23 2,000 60.42 25,000 15.11 250 111.65 2,500 53.69 50,000 9.36 300 109.08 5,000 35.21 100,000 5.38 500 98.81 7,500 30.07 150,000 2.87

Table II - Utilization Rate by Coinsurance *

 Coinsurance Utilization Rate Coinsurance Utilization Rate 100% 1.14 70% 0.93 95% 1.10 65% 0.91 90% 1.07 60% 0.89 85% 1.03 55% 0.87 80% 1. 50% or less 0.86 75% 0.97

Table - III - Lifetime-Maximum Values by

 Lifetime Maximum Amount Lifetime Maximum Value \$5,000,000 or more \$ 0.23 2,000,000 0.17 1,000,000 0.00 750,000 -0.28 500,000 -0.55 250,000 -1.78 100,000 -7.67 50,000 -13.34 25,000 -21.54

* Values were constructed by the Montana Insurance Department, using the 1994 Tillinghast Group Medical Insurance Rate Manual as a reference.

(2) Filing of standard and basic health benefit plans for approval by the commissioner must include a description of the small employer carrier's benefit value method, an actuarial certification that the formula's expected claims costs, utilization rates and values used are based on commonly accepted actuarial assumptions, and the calculation of the benefit values of the standard and basic plans being filed.

History: Sec. 33-1-313, 33-22-1812 and 33-22-1822, MCA; IMP, Sec. 33-22-1802, 33-22-1809, 33-22-1811, and 33-22-1812, MCA; NEW, 1994 MAR p. 1528, Eff. 6/10/94; AMD, 1994 MAR p. 2926, Eff. 11/11/94; AMD, 1996 MAR p. 141, Eff. 10/13/95; AMD, 1998 MAR p. 2020, Eff. 6/26/98.

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