Community rating
Encyclopedia
Health insurance
Health insurance is insurance against the risk of incurring medical expenses among individuals. By estimating the overall risk of health care expenses among a targeted group, an insurer can develop a routine finance structure, such as a monthly premium or payroll tax, to ensure that money is...
, which requires health insurance providers to offer health insurance policies within a given territory at the same price to all persons without medical underwriting
Medical Underwriting
Medical underwriting is an insurance term referring to the use of medical or health status information in the evaluation of an applicant for coverage . As part of the underwriting process, health information may be used in making two related decisions: whether to offer or deny coverage; and what...
, regardless of their health status.
Pure community rating prohibits insurance rate variations based on demographic characteristics such as age or gender, whereas adjusted or modified community rating allows insurance rate variations based on demographic characteristics such as age or gender.
Concept
Community rating, as a basis for premium calculation, is fundamentally different from the usual method of determining insurance premiums, i.e. risk rating. In a risk rated insurance market, an insurer calculates the premium payable by a potential policy holder in order to enter into an insurance contract on the basis of various factors particular to that individual, such as the risk of a claim occurring, and the value of any such claims during the term of an insurance policy. In a community rated market, the insurer may not calculate premium on the basis of the risk factors attaching to the particular person wishing to purchase an insurance contract, but rather the risk factors applying to all persons within the market as a whole. Thus, in a community rated market, the insurer evaluates the risk factors of market population, and not those of any one person when calculating premiums. Some form of risk equalizationRisk equalization
Risk equalization is a way of equalizing the risk profiles of insurance members in order to avoid loading premiums on the insured to some predetermined extent.- Health care :...
also often exists in a community rated system.
- Health insurers vary premium rates based on case characteristics, such as:
- benefit design
- family composition
- demographic characteristics:
- age
- gender
- geographic area
- occupation
- industry
- lifestyle factors:
- tobacco use
- weight
- health status and claims history
- Community rating — prohibits insurers from varying rates based on health status or claims history
- Pure community rating — allows insurers to vary rates based on benefit design and family composition only
- Limited variation in rates by geographic area is sometimes included in the pure community rating category (e.g. New YorkNew YorkNew York is a state in the Northeastern region of the United States. It is the nation's third most populous state. New York is bordered by New Jersey and Pennsylvania to the south, and by Connecticut, Massachusetts and Vermont to the east...
)
- Limited variation in rates by geographic area is sometimes included in the pure community rating category (e.g. New York
- Adjusted (modified) community rating — allows insurers to also vary rates based on demographic characteristics (e.g. age and gender) and lifestyle factors (e.g. tobacco use)
- Pure community rating — allows insurers to vary rates based on benefit design and family composition only
- Guaranteed issue — requires insurers to issue insurance to any eligible applicant without regard to health status or other case characteristics
- The federal HIPAA Act of 1996Health Insurance Portability and Accountability ActThe Health Insurance Portability and Accountability Act of 1996 was enacted by the U.S. Congress and signed by President Bill Clinton in 1996. It was originally sponsored by Sen. Edward Kennedy and Sen. Nancy Kassebaum . Title I of HIPAA protects health insurance coverage for workers and their...
requires that all small group (2 to 50 employee) health insurance be guaranteed issue - Five (MaineMaineMaine is a state in the New England region of the northeastern United States, bordered by the Atlantic Ocean to the east and south, New Hampshire to the west, and the Canadian provinces of Quebec to the northwest and New Brunswick to the northeast. Maine is both the northernmost and easternmost...
, MassachusettsMassachusettsThe Commonwealth of Massachusetts is a state in the New England region of the northeastern United States of America. It is bordered by Rhode Island and Connecticut to the south, New York to the west, and Vermont and New Hampshire to the north; at its east lies the Atlantic Ocean. As of the 2010...
, New JerseyNew JerseyNew Jersey is a state in the Northeastern and Middle Atlantic regions of the United States. , its population was 8,791,894. It is bordered on the north and east by the state of New York, on the southeast and south by the Atlantic Ocean, on the west by Pennsylvania and on the southwest by Delaware...
, New YorkNew YorkNew York is a state in the Northeastern region of the United States. It is the nation's third most populous state. New York is bordered by New Jersey and Pennsylvania to the south, and by Connecticut, Massachusetts and Vermont to the east...
, VermontVermontVermont is a state in the New England region of the northeastern United States of America. The state ranks 43rd in land area, , and 45th in total area. Its population according to the 2010 census, 630,337, is the second smallest in the country, larger only than Wyoming. It is the only New England...
) of the seven states which require community rating for individual health insurance also require its guaranteed issue
- The federal HIPAA Act of 1996
Occurrence
Community rating of supplemental private health insurance:- AustraliaAustraliaAustralia , officially the Commonwealth of Australia, is a country in the Southern Hemisphere comprising the mainland of the Australian continent, the island of Tasmania, and numerous smaller islands in the Indian and Pacific Oceans. It is the world's sixth-largest country by total area...
— lifetime community rating of private hospital insurance supplemental to universal publicly-financed hospital insurance - IrelandIrelandIreland is an island to the northwest of continental Europe. It is the third-largest island in Europe and the twentieth-largest island on Earth...
— pure community rating of all private health insurance supplemental to universal publicly-financed health insurance
Community rating of basic private health insurance:
- NetherlandsNetherlandsThe Netherlands is a constituent country of the Kingdom of the Netherlands, located mainly in North-West Europe and with several islands in the Caribbean. Mainland Netherlands borders the North Sea to the north and west, Belgium to the south, and Germany to the east, and shares maritime borders...
— age and gender rating illegal = pure community rating; individual guaranteed issue- individual mandate with low-income government subsidies for 40% of households
- SwitzerlandSwitzerlandSwitzerland name of one of the Swiss cantons. ; ; ; or ), in its full name the Swiss Confederation , is a federal republic consisting of 26 cantons, with Bern as the seat of the federal authorities. The country is situated in Western Europe,Or Central Europe depending on the definition....
— age and gender rating illegal = pure community rating; individual guaranteed issue- individual mandate with low-income government subsidies for 40% of households
- within the United States:
- Community rating for individual and small group (2 to 50 employees) health insurance:
- New YorkNew YorkNew York is a state in the Northeastern region of the United States. It is the nation's third most populous state. New York is bordered by New Jersey and Pennsylvania to the south, and by Connecticut, Massachusetts and Vermont to the east...
— age and gender rating illegal = pure community rating; individual guaranteed issue - VermontVermontVermont is a state in the New England region of the northeastern United States of America. The state ranks 43rd in land area, , and 45th in total area. Its population according to the 2010 census, 630,337, is the second smallest in the country, larger only than Wyoming. It is the only New England...
— age and gender rating illegal = pure community rating for small group health insurance; individual guaranteed issue- age and gender rating illegal = pure community rating for individual health insurance from BlueCross BlueShieldBlue Cross and Blue Shield AssociationThe Blue Cross Blue Shield Association is a federation of 39 separate health insurance organizations and companies in the United States. Combined, they directly or indirectly provide health insurance to over 100 million Americans. The history of Blue Cross dates back to 1929, while the history of...
and HMOHealth maintenance organizationA health maintenance organization is an organization that provides managed care for health insurance contracts in the United States as a liaison with health care providers...
s - age and gender rating combined limited to 1.5:1 (150 percent) for individual health insurance from other insurance companies
- age and gender rating illegal = pure community rating for individual health insurance from BlueCross BlueShield
- MaineMaineMaine is a state in the New England region of the northeastern United States, bordered by the Atlantic Ocean to the east and south, New Hampshire to the west, and the Canadian provinces of Quebec to the northwest and New Brunswick to the northeast. Maine is both the northernmost and easternmost...
— age rating limited to 1.5:1 (150 percent); gender rating illegal; individual guaranteed issue- smoking status rating unlimited
- MassachusettsMassachusettsThe Commonwealth of Massachusetts is a state in the New England region of the northeastern United States of America. It is bordered by Rhode Island and Connecticut to the south, New York to the west, and Vermont and New Hampshire to the north; at its east lies the Atlantic Ocean. As of the 2010...
— age rating limited to 2:1 (200 percent); gender rating illegal; individual guaranteed issue- individual and employer mandates with low-income government subsidies or exemptions
- New JerseyNew JerseyNew Jersey is a state in the Northeastern and Middle Atlantic regions of the United States. , its population was 8,791,894. It is bordered on the north and east by the state of New York, on the southeast and south by the Atlantic Ocean, on the west by Pennsylvania and on the southwest by Delaware...
— age and gender rating combined limited to 3.5:1 (350 percent); individual guaranteed issue - Washington — age rating limited to 3.75:1 (375 percent); gender rating illegal
- OregonOregonOregon is a state in the Pacific Northwest region of the United States. It is located on the Pacific coast, with Washington to the north, California to the south, Nevada on the southeast and Idaho to the east. The Columbia and Snake rivers delineate much of Oregon's northern and eastern...
— age rating unlimited ; gender rating illegal
- New York
- Community rating for small group (2 to 50 employees) health insurance only:
- MarylandMarylandMaryland is a U.S. state located in the Mid Atlantic region of the United States, bordering Virginia, West Virginia, and the District of Columbia to its south and west; Pennsylvania to its north; and Delaware to its east...
— age rating limited to 2.8:1 (280 percent); gender rating illegal - New HampshireNew HampshireNew Hampshire is a state in the New England region of the northeastern United States of America. The state was named after the southern English county of Hampshire. It is bordered by Massachusetts to the south, Vermont to the west, Maine and the Atlantic Ocean to the east, and the Canadian...
— age rating limited to 4:1 (400 percent); gender rating illegal - Rhode IslandRhode IslandThe state of Rhode Island and Providence Plantations, more commonly referred to as Rhode Island , is a state in the New England region of the United States. It is the smallest U.S. state by area...
* — age and gender rating combined limited to 4:1 (400 percent)- *health status rating limited to ± 10% of community rating
- ColoradoColoradoColorado is a U.S. state that encompasses much of the Rocky Mountains as well as the northeastern portion of the Colorado Plateau and the western edge of the Great Plains...
— age rating unlimited; gender rating illegal - ConnecticutConnecticutConnecticut is a state in the New England region of the northeastern United States. It is bordered by Rhode Island to the east, Massachusetts to the north, and the state of New York to the west and the south .Connecticut is named for the Connecticut River, the major U.S. river that approximately...
— age and gender rating unlimited
- Maryland
- No community rating, but age rating limited and/or gender rating illegal and/or health status rating limited:
- Age rating limited in individual health insurance: to 3:1 (300 percent) in MinnesotaMinnesotaMinnesota is a U.S. state located in the Midwestern United States. The twelfth largest state of the U.S., it is the twenty-first most populous, with 5.3 million residents. Minnesota was carved out of the eastern half of the Minnesota Territory and admitted to the Union as the thirty-second state...
, to 4:1 (400 percent) in New HampshireNew HampshireNew Hampshire is a state in the New England region of the northeastern United States of America. The state was named after the southern English county of Hampshire. It is bordered by Massachusetts to the south, Vermont to the west, Maine and the Atlantic Ocean to the east, and the Canadian...
, to 5:1 (500 percent) in North DakotaNorth DakotaNorth Dakota is a state located in the Midwestern region of the United States of America, along the Canadian border. The state is bordered by Canada to the north, Minnesota to the east, South Dakota to the south and Montana to the west. North Dakota is the 19th-largest state by area in the U.S....
and South DakotaSouth DakotaSouth Dakota is a state located in the Midwestern region of the United States. It is named after the Lakota and Dakota Sioux American Indian tribes. Once a part of Dakota Territory, South Dakota became a state on November 2, 1889. The state has an area of and an estimated population of just over... - Age rating limited in small group health insurance: to 3:1 (300 percent) in MinnesotaMinnesotaMinnesota is a U.S. state located in the Midwestern United States. The twelfth largest state of the U.S., it is the twenty-first most populous, with 5.3 million residents. Minnesota was carved out of the eastern half of the Minnesota Territory and admitted to the Union as the thirty-second state...
and South DakotaSouth DakotaSouth Dakota is a state located in the Midwestern region of the United States. It is named after the Lakota and Dakota Sioux American Indian tribes. Once a part of Dakota Territory, South Dakota became a state on November 2, 1889. The state has an area of and an estimated population of just over... - Gender rating illegal in individual health insurance in: MinnesotaMinnesotaMinnesota is a U.S. state located in the Midwestern United States. The twelfth largest state of the U.S., it is the twenty-first most populous, with 5.3 million residents. Minnesota was carved out of the eastern half of the Minnesota Territory and admitted to the Union as the thirty-second state...
, MontanaMontanaMontana is a state in the Western United States. The western third of Montana contains numerous mountain ranges. Smaller, "island ranges" are found in the central third of the state, for a total of 77 named ranges of the Rocky Mountains. This geographical fact is reflected in the state's name,...
, North DakotaNorth DakotaNorth Dakota is a state located in the Midwestern region of the United States of America, along the Canadian border. The state is bordered by Canada to the north, Minnesota to the east, South Dakota to the south and Montana to the west. North Dakota is the 19th-largest state by area in the U.S....
- Gender rating limited to 1.2:1 (120 percent) in New MexicoNew MexicoNew Mexico is a state located in the southwest and western regions of the United States. New Mexico is also usually considered one of the Mountain States. With a population density of 16 per square mile, New Mexico is the sixth-most sparsely inhabited U.S...
- Gender rating limited to 1.2:1 (120 percent) in New Mexico
- Gender rating illegal in small group health insurance in: CaliforniaCaliforniaCalifornia is a state located on the West Coast of the United States. It is by far the most populous U.S. state, and the third-largest by land area...
, IowaIowaIowa is a state located in the Midwestern United States, an area often referred to as the "American Heartland". It derives its name from the Ioway people, one of the many American Indian tribes that occupied the state at the time of European exploration. Iowa was a part of the French colony of New...
, MichiganMichiganMichigan is a U.S. state located in the Great Lakes Region of the United States of America. The name Michigan is the French form of the Ojibwa word mishigamaa, meaning "large water" or "large lake"....
, MinnesotaMinnesotaMinnesota is a U.S. state located in the Midwestern United States. The twelfth largest state of the U.S., it is the twenty-first most populous, with 5.3 million residents. Minnesota was carved out of the eastern half of the Minnesota Territory and admitted to the Union as the thirty-second state...
, MontanaMontanaMontana is a state in the Western United States. The western third of Montana contains numerous mountain ranges. Smaller, "island ranges" are found in the central third of the state, for a total of 77 named ranges of the Rocky Mountains. This geographical fact is reflected in the state's name,...
, North DakotaNorth DakotaNorth Dakota is a state located in the Midwestern region of the United States of America, along the Canadian border. The state is bordered by Canada to the north, Minnesota to the east, South Dakota to the south and Montana to the west. North Dakota is the 19th-largest state by area in the U.S.... - Health status rating limited (but no guaranteed issue) of individual health insurance:
- IowaIowaIowa is a state located in the Midwestern United States, an area often referred to as the "American Heartland". It derives its name from the Ioway people, one of the many American Indian tribes that occupied the state at the time of European exploration. Iowa was a part of the French colony of New...
— health status rating limited to 1.35:1 (135 percent) - New HampshireNew HampshireNew Hampshire is a state in the New England region of the northeastern United States of America. The state was named after the southern English county of Hampshire. It is bordered by Massachusetts to the south, Vermont to the west, Maine and the Atlantic Ocean to the east, and the Canadian...
— health status rating limited to 1.5:1 (150 percent) - MinnesotaMinnesotaMinnesota is a U.S. state located in the Midwestern United States. The twelfth largest state of the U.S., it is the twenty-first most populous, with 5.3 million residents. Minnesota was carved out of the eastern half of the Minnesota Territory and admitted to the Union as the thirty-second state...
— health status rating limited to 1.67:1 (167 percent) - NevadaNevadaNevada is a state in the western, mountain west, and southwestern regions of the United States. With an area of and a population of about 2.7 million, it is the 7th-largest and 35th-most populous state. Over two-thirds of Nevada's people live in the Las Vegas metropolitan area, which contains its...
— health status rating limited to 1.75:1 (175 percent) - South DakotaSouth DakotaSouth Dakota is a state located in the Midwestern region of the United States. It is named after the Lakota and Dakota Sioux American Indian tribes. Once a part of Dakota Territory, South Dakota became a state on November 2, 1889. The state has an area of and an estimated population of just over...
— health status rating limited to 1.86:1 (186 percent) - UtahUtahUtah is a state in the Western United States. It was the 45th state to join the Union, on January 4, 1896. Approximately 80% of Utah's 2,763,885 people live along the Wasatch Front, centering on Salt Lake City. This leaves vast expanses of the state nearly uninhabited, making the population the...
— health status rating limited to 1.86:1 (186 percent) - LouisianaLouisianaLouisiana is a state located in the southern region of the United States of America. Its capital is Baton Rouge and largest city is New Orleans. Louisiana is the only state in the U.S. with political subdivisions termed parishes, which are local governments equivalent to counties...
— health status rating limited to 2:1 (200 percent) - KentuckyKentuckyThe Commonwealth of Kentucky is a state located in the East Central United States of America. As classified by the United States Census Bureau, Kentucky is a Southern state, more specifically in the East South Central region. Kentucky is one of four U.S. states constituted as a commonwealth...
— health status rating limited to 2.08:1 (208 percent) - IdahoIdahoIdaho is a state in the Rocky Mountain area of the United States. The state's largest city and capital is Boise. Residents are called "Idahoans". Idaho was admitted to the Union on July 3, 1890, as the 43rd state....
— health status rating limited to 3:1 (300 percent)
- Iowa
- Age rating limited in individual health insurance: to 3:1 (300 percent) in Minnesota
- Community rating for individual and small group (2 to 50 employees) health insurance: