Integrating risk adjustment and enrollee premiums in health plan payment

Abstract

In two important health policy contexts - private plans in Medicare and the new state-run "Exchanges" created as part of the Affordable Care Act (ACA) - plan payments come from two sources: risk-adjusted payments from a Regulator and premiums charged to individual enrollees. This paper derives principles for integrating risk-adjusted payments and premium policy in individual health insurance markets based on fitting total plan payments to health plan costs per person as closely as possible. A least squares regression including both health status and variables used in premiums reveals the weights a Regulator should put on risk adjusters when markets determine premiums. We apply the methods to an Exchange-eligible population drawn from the Medical Expenditure Panel Survey (MEPS).

Keywords: Exchanges; Health insurance; I13; I18; Medicare; Premiums; Risk adjustment.

Figure 1

Risk Adjustment Relative Weights Source: Author’s analysis of risk-adjustment regression results. Model 2 includes risk-adjustment variables only. Model 5 imposes budget and age ratio constraints; no-history indicates health status information is missing.