Session 106 PD, Reinsurance for Capital Management of Health Insurance Business. Moderator/Presenter: Michael David Mulcahy, FSA, MAAA

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1 Session 106 PD, Reinsurance for Capital Management of Health Insurance Business Moderator/Presenter: Michael David Mulcahy, FSA, MAAA Presenters: Rob Healy Katrina E. Spillane, FSA, MAAA Brad Quinn

2 Collateralized Health Reinsurance Overview June 17, Aetna Life Insurance Company. All rights reserved.

3 Executive Summary Aetna launched a non-recourse collateralized reinsurance program for a portion of its commercial insured healthcare business portfolio in December 2010 Six separate transactions with a total of $1 billion of coverage completed to date Utilizes a highly innovative structure that allows Aetna to transfer risk to capital markets via reinsurance Program allows Aetna to improve its capital efficiency, obtain catastrophic risk protection and enhance its financial flexibility Risk Modeling performed by Milliman provides expected loss and probability of attachment for each transaction June 17, 2015 Aetna Life Insurance Company 2

4 Conceptual Overview Structure transfers health insurance risk to reinsurer whose investors commit their capital in exchange for a coupon payment Health insurance risk + premium Floating rate + additional spread for risk HEALTH INSURER Catastrophic protection + reduced cost of capital REINSURER Capital at risk if medical claims exceed predefined threshold INVESTORS Actuarial Monte Carlo modeling is used to estimate the magnitude and probability of investors expected losses June 17, 2015 Aetna Life Insurance Company 3

5 Structure Overview Reinsurance debt is non-recourse to the insurer and does not impact the insurer s debt-to-capitalization ratio Health Insurance-Linked Debt Excess of Loss Reinsurance Agreement Proceeds Insurer Premiums Reinsurer Interest Investors Reinsurance payouts Principal Repayment less reinsurance payouts Insurer transfers its MBR (1) risk in a defined corridor to investors via reinsurance contracts Capital benefit provided by reinsurance lowers insurer s cost of capital (1) Medical claims as a percent of premium June 17, 2015 Aetna Life Insurance Company 4

6 Structural Overview Probability of Attachment under Excess of Loss (XOL) Reinsurance Agreement The XOL attachment point is X% MBR and exhaustion point Y% MBR with a probability of A bps and less than B bps, respectively A portion of the medical Risk Coverage XOL Attachment/ Exhaustion Points (MBR) Probability of Attachment / Exceedance claims for the subject Y% MBR <B bps business is covered by the insurer s reserves and capital Reinsurance $[ ]mm If the subject business MBR does not exceed the XOL attachment point, no payment Insurer Capital $[ ]mm X% MBR Z% MBR A bps is triggered under the XOL agreement Ceded Premiums $[ ]mm ceding commission $[ ]mm 0% June 17, 2015 Aetna Life Insurance Company 5

7 Benefits to Insurer Improves insurer s capital efficiency, provides catastrophic risk protection and enhances financial flexibility 1. Improves Capital Efficiency 2. Provides Catastrophic Risk Protection 3. Enhances Financial Flexibility Lowers capital requirement for the underlying business Improves Return on Capital Earnings protection in the event MBR (medical claims as % of premium) exceeds a level in excess of expected (e.g. 95% on an expected MBR of 85%) Diversifies funding sources Lowers cost of capital by replacing equity with reinsurance at lower cost No impact to debt-tocapitalization ratio June 17, 2015 Aetna Life Insurance Company 6

8 Risk Modeling Overview Risk Modeling provides expected loss and probability of attachment that create the groundwork for these transactions Trend Variability Portfolio Size Pricing Lags Rating Formula Pandemic Risk The model simulates many paths and the distribution of results is used to assess the risk of exceeding a defined MBR level Pricing and Rating Determinant Factors: Expected Losses and Probabilities of Attachment and Exhaustion June 17, 2015 Aetna Life Insurance Company 7

9 Reinsurance Payment Mechanism Reinsurance payment (and loss of investors principal) is triggered if MBR exceeds a defined level. Trigger level is set to be remote and primarily driven by pandemic risk. Option 1: Indemnity Trigger Reinsurance payment triggered by insurer s actual claims experience Option 2: Parametric Trigger Trigger is tied to a Health Index rather than an individual insurer s claims experience Indemnity Trigger ties reinsurance protection directly to the performance of the subject business ( no basis risk ) June 17, 2015 Aetna Life Insurance Company 8

10 Subject Business Subject business is a carefully defined block of plain vanilla policies with geographically dispersed risk Subject Business Overview 1 Written on a single legal entity Block of Business 2 Plain vanilla policies 3 Geographically diversified risk June 17, 2015 Aetna Life Insurance Company 9

11 Surplus Relief Reinsurance CASE STUDY

12 Case Study A 1.5 m member Non-profit Health Plan in the Midwest Reinsurance client for 15 years Holding company ownership structure including Two insurance companies: HMO P&C 2

13 Case Study ABC Holding Company ABC Health Plan 1 ABC Health Plan 2 ABC Foundation ABC Research Institute ABC Affilliated Services ABC Health Management ABC Self Insured ABC Insurance Company 3

14 Problem/Challenge HMO was primary vehicle to issue policies to their commercial and government membership Market and needs of their members changed More and more policies issued under the P&C Company Including their existing HMO membership, who began migrating over to Ins. Company, attracted to PPO and HSA plans options not offered by HMO 4

15 Problem/Challenge $100m surplus deficit as a result Previously, HMO holding company would instruct HMO to issue a Surplus note, transfer monies from HMO to P&C Simple Efficient Inexpensive And so company proceeded to do same this time (Note: HMO regulated by State Health Dept and Ins. Company by State commerce) 5

16 SOLUTION Company now had a surplus problem that needed resolved. Sources of capital * Raise funds- as Non-profit, limited market appeal * Retained Earnings- minimal margins (non-profit) with rapid growth * Borrow- expensive and payment eat into limited margins * Surplus Reinsurance 6

17 Example of Traditional QS A Simple Example of Traditional Quota Share Premium Claims Expenses RBC Capital Gross Profit ROE Before Reinsurance $100M $80M $5M $15M $45M $15M 33% 60% $60M $48M $3M $9M $27M $9M NA After Reinsurance $40M $32M $2M $6M $18M $6M 33% Assumptions: 60% Reinsurance Ceded RBC = 15% of Premium 60% of Expenses Shared Capital Required = 300% of RBC Surplus requirement reduced from $45M to $18M However, you had to part with profits! 7

18 Example of Surplus Relief A Simple Example of Surplus Relief Financials Premium Claims Expenses RBC Capital Profit Exp. Refund Gross Profit ROE Before Reinsurance $100M $80M $5M $15M $45M $15M NA $15M 33% 60% $60M $48M $1M $9M $27M $11M $10.4M $600K NA After Reinsurance $40M $32M $5M $6M $18M $4M $10.4M $14.4M 80% Assumptions: 60% Reinsurance Ceded RBC = 15% of Premium 1% Reinsurer Risk Charge Fee 20% of Expenses Shared Capital Required = 300% of RBC Surplus requirement reduced from $45M to $18M Cost to free up $27M of Surplus = $600k = 2.2% 8

19 HMO RBC EXAMPLE- QUOTA SHARE and STOP LOSS 50% quota share reinsurance..75% reinsurance fee. 6.5% expense allowance % Stop Loss Cover Ceding Carrier-100% Gross Loss Ratio (GLR) 92% 91.50% 91.75% 94% 91% 105% 90.00% 90% 104% Earned Premium (100%) % 1,000,000,000 1,000,000,000 1,000,000,000 1,000,000,000 1,000,000,000 1,000,000,000 1,000,000,000 1,000,000,000 1,000,000,000 Claims Incurred (GLR) 920,000, ,000, ,500, ,000, ,000,000 1,050,000, ,000, ,000,000 1,035,000,000 Expenses allocated 6.50% 65,000,000 65,000,000 65,000,000 65,000,000 65,000,000 65,000,000 65,000,000 65,000, ,000,000 Total Combined Ratio 98.50% 98.00% 98.25% % 97.50% % 96.50% 96.50% % Reinsured Portion Reinsured Premium 50.00% 500,000, ,000, ,000, ,000, ,000, ,000, ,000, ,000, ,000,000 Less: Claims Incurred (GLR) 460,000, ,500, ,750, ,000, ,000, ,000, ,000, ,000, ,500,000 Less: Expenses Allowances 6.50% 32,500,000 32,500,000 32,500,000 32,500,000 32,500,000 32,500,000 32,500,000 32,500,000 32,500,000 Subtotal (UW margin) 7,500,000 10,000,000 8,750,000-2,500,000 12,500,000 (57,500,000) 17,500,000 17,500,000 (50,000,000) Less: Reinsurer Fixed Fee 0.75% 3,750,000 3,750,000 3,750,000 3,750,000 3,750,000 3,750,000 3,750,000 3,750,000 4,000,000 Subtotal-AHS Margins 3,750,000 6,250,000 5,000,000 (6,250,000) 8,750,000 (61,250,000) 13,750,000 13,750,000 (54,000,000) Experience Refund 3,750,000 6,250,000 5,000,000 (6,250,000) 8,750,000 (61,250,000) 13,750,000 13,750,000 (54,000,000) Less: Prior Carryforward (6,250,000) 0 (61,250,000) (47,500,000) 0 Net/ Loss Carryforward 3,750,000 6,250,000 5,000,000 (6,250,000) 2,500,000 (61,250,000) (47,500,000) (33,750,000) (54,000,000) AHC capital reduction (7,250,000) 0 0 (losses above 110% GLR) Notes: HMO Combined Gross Loss Ratio capped from 100.0%-110.0% via Stop Loss Policy Reinsurer Buys Stop Loss Policy from HMO that caps Reinsurer losses at 110.0%. Pays HMO.50% Premium (pass thru - credit Prem, debit Exp. Refund) Reinsurer pays losses in current year excess of 100.0% GLR and collects from next years Experience Refund (profits) Capital available = $500m QS / 15 (at current 5 to 1 leverage ratio) = $100m Effective cost of capital= $ 3,750,000 / $ 100m = 3.75% Transaction credited as Reinsurance Accounting and does NOT add to debt Reinsurers QS up to 75% and $500,000,000 GWP (2 week Underwriting) and $3,000,000,000 GWP (30 days to underwrite) 9

20 Structure of a RBC Relief Deal The reinsurance is designed to meet risk transfer and generate reinsurance accounting If business is profitable, profits in excess of a Risk Charge are returned to the client by an experience refund Expense allowances may not include overhead expenses risk transfer rules require only renewal expenses directly related to the business be covered Assets are typically left with the ceding company by using mod-co or funds withheld. Unless losses occur, only cash transferred is the risk charge There may be caps on losses under some structures. Some contracts may allow the reinsurer to increase premiums or risk charges, or reduce expense allowances 10

21 Structure of a RBC Relief Deal If losses occur, they are tracked in a loss carryforward and repaid to the reinsurer out of future profits (if they emerge) The ceding company must repay any loss carryforward if they terminate the transaction (some transactions may have a date after which losses don t have to be repaid) Reinsurer will typically want the insurer to maintain some quota share of the business to insure they have a risk interest Investment risk may or may not be covered under the agreement (not required to be covered to have risk transfer for health business) The premium and the reserves are ceded to the Reinsurer and therefore the Capital is reduced 11

22 What the Reinsurer Will Analyze to determine Feasibility and Cost How Risky is the Business being Reinsured? Product Type Profitability Volatility and Historical experience Expense levels Ability of client to adjust rates to reflect experience Reinsurance Structure Volume of business being reinsured Duration of Agreement and any termination provisions Any loss mitigating features in the Treaty Financial Strength of the Ceding Company 12

23 Administrative Considerations Depending on the size of the transaction, and ceding company/reinsurer familiarity, the transaction may take as little as a month or up to a year to finalize. Capital benefit is driven by the amount of premium/claims ceded, so having the transaction in early in the year could be important to meet a specific capital saving target Reinsurer may or may not ask to be involved with rate setting/reserving while the transaction is in place. Reporting almost always on a bulk basis. Reinsurer is rarely involved with claim decisions. ACA reimbursements (the 3 R s) and Fees can cause timing problems and need to be spelled out in the contract if they apply to the covered business. 13

24 Brad Quinn

25 Reinsurance for Capital Management of Health Insurance Business Katrina Spillane AVP, Pricing 1

26 Capital Required capital is the amount of capital a company must hold to support fluctuations in their business Known as Risk Based Capital (RBC) in the US Minimum Continuing Capital and Surplus Requirements (MCCSR) in Canada 2

27 Capital The four main components of RBC include: C1: Asset Default Risk C2: Insurance Risk C3: Interest Rate Risk C4: Business Risk 3

28 Capital Formula The RBC formula includes a covariance adjustment to take into account the independence of C2 risk from C1 and C3 risk. In general, this formula is: [C2 2 + (C1 + C3) 2 ] + C4 In reality, this formula is much more complex Formulas are different depending on whether you are completing a life statement or a health statement The actual capital calculation is dependent upon the loss ratio C0: Insurance Affiliate and Off-Balance Sheet Risk is introduced Some of the risk categories are broken down into more specific groupings 4

29 Capital for Health The largest component of capital on health business is the C2 Risk The C2 Risk component is a factor times the premiums The factor varies by: Underlying product Net premium levels State of domicile 5

30 RBC Factors Product C2 RBC Factors * Comprehensive Medical 9.0% Medicare 9.0% Medicare Supplement 6.7% Dental and Vision 7.6% Stand-alone Medicare Part D Coverage (excluding supplemental benefits) Supplemental benefits within Standalone Medicare Part D 15.1% 35.0% Stop Loss 25.0% * Factors assume over $25M of net earned premium 6

31 The Answer Reinsurance 7

32 Reinsurance A few reinsurance terms: Modified Coinsurance Coinsurance Funds Withheld Risk Charge Expense Allowance Experience Refund Loss Carryforward 8

33 How is Reinsurance Structured? Reinsurance for the purpose of capital relief can be structured in such a way that the Cedant gets C2 risk off their books but still retains all the profit less a risk charge The Cedant enters into a Coinsurance Funds Withheld or Modified Coinsurance quota share arrangement with the Reinsurer At inception: the Cedant pays the Reinsurer a premium equal to the quota share of statutory reserves Either (i) a notional funds withheld account is established (a payable for the Cedant and receivable for the Reinsurer); or (ii) the Reinsurer pays the Cedant an Initial Modco Adjustment The net effect is that at inception, no funds are exchanged (i.e. the assets are deposited back) 9

34 How is Reinsurance Structured? Going forward, The Cedant pays the Reinsurer the quota share of Premiums, Any decrease in statutory reserve The risk charge The Reinsurer pays the Cedant the quota share of Expense allowance Claims Any increases in statutory reserve Experience refund The net result is settled either by (i) a change in the balance of the Funds Withheld Account; or (ii) a Modco Reserve Adjustment 10

35 How is Reinsurance Structured? Key Things to Remember: On an expected basis (i.e. the business is profitable), the only money that changes hands is the Risk Charge. The Cedant continues to retain the assets supporting the statutory reserve for the reinsured business on its balance sheet Reporting is typically done on a monthly basis, with settlement occurring on a quarterly basis Bulk reporting the Reinsurer never receives individual claim information unless during an audit Other features, such as expense allowances and loss corridors, may be part of the transaction and are designed to reduce the Cedant s cost while still meeting risk transfer 11

36 Risk Transfer According to the Life and Health Reinsurance Agreements Model Regulation, the Cedant shall not take credit for a reinsurance arrangement unless all of the significant risks are reinsured Risk categories include: Morbidity Mortality Lapse Credit Quality Reinvestment Disintermediation For health insurance, significant risks are defined as morbidity and lapse 12

37 Credit for Reinsurance Appendix A-791 of the NAIC Accounting Practices & Procedures Manual offers guidance on the application of the model regulation to specific reinsurance features This guidance does not apply to YRT reinsurance, assumption reinsurance, stop loss arrangements or cat covers 13

38 Appendix A-791, Paragraph 2a 2. No insurer shall, for reinsurance ceded, reduce any liability or establish any asset in any statutory financial statement if, by the terms of the reinsurance agreement, in substance or effect, any of the following conditions exist: a. Renewal expense allowances provided or to be provided to the ceding insurer by the reinsurer in any accounting period are not sufficient to cover anticipated allocable renewal expenses of the ceding insurer on the portion of the business reinsured, unless a liability is established for the present value of the shortfall 14

39 Risk Transfer Expense Allowance Credit for reinsurance is prohibited where the ceding insurer is afforded a large ceding commission at the inception of the agreement resulting in a significant increase in surplus only to have such surplus increase be drained away in subsequent periods because renewal expense allowances provided under the agreement are insufficient to cover the direct allocable costs estimated at the time the business is reinsured. A Cedant may avoid complete disallowance of credit for reinsurance if they establish a liability for the present value of the shortfall between the expense allowance and the directly attributable expenses 15

40 What expenses are in the EA? Q: What should be included in the renewal expense allowances with regard to direct expenses? An allocation of salaries? Computer usage? Or just marginal expenses directly related to the business reinsured such as claim payment expenses, postage, etc,? A: In determining what the ceding insurer should include in the renewal expenses with regard to direct expenses, there should be an allocation of all renewal expenses anticipated at the time the business is reinsured including salaries, computer usage, postage, etc. 16

41 Appendix A-791, Paragraph 2b 2.b The ceding insurer can be deprived of surplus or assets at the reinsurer s option or automatically upon the occurrence of some event, such as the insolvency of the ceding insurer, except that termination of the reinsurance agreement by the reinsurer for nonpayment of reinsurance premiums or other amounts due, such as modified coinsurance reserve adjustments, interest and adjustments on funds withheld, and tax reimbursements, shall not be considered to be such a deprivation of surplus or assets; 17

42 Appendix A-791, Paragraph 2c 2.c The ceding insurer is required to reimburse the reinsurer for negative experience under the reinsurance agreement, except that neither offsetting experience refunds against current and prior years losses under the agreement nor payment by the ceding insurer of an amount equal to the current and prior years losses under the agreement upon voluntary termination of in force reinsurance by the ceding insurer shall be considered such a reimbursement to the reinsurer for negative experience. Voluntary termination does not include situations where termination occurs because of unreasonable provisions which allow the reinsurer to reduce its risk under the agreement. An example of such a provision is the right of the reinsurer to increase reinsurance premiums or risk and expense charges to excessive levels forcing the ceding company to prematurely terminate the reinsurance treaty. 18

43 Risk Transfer ER and LCF Experience Refunds are not considered part of surplus or assets under Paragraph 2b While they serve a powerful function, they are not a necessary feature for the Cedant to take credit for reinsurance Furthermore, Paragraph 2c allows for losses to be placed into a Loss Carryfoward and any current Experience Refund can offset that Loss Carryforward However, if the Cedant decides to voluntarily terminate the reinsurance arrangement while in carrying a Loss Carryforward, they are depriving the Reinsurer of any future profits that could be used to repay that Loss Carryforward. Therefore, credit for reinsurance is allowed when the reinsurance arrangement requires the Cedant to pay the amount of the Loss Carryforward upon voluntary termination 19

44 Appendix A-791, Paragraph 2k 2.k The reinsurance agreement is entered into for the principal purpose of producing significant surplus aid for the ceding insurer, typically on a temporary basis, while not transferring all of the significant risks inherent in the business reinsured and, in substance or effect, the expected potential liability to the ceding insurer remains basically unchanged. 20

45 The 10/10 Rule A metric used by accountants in P&C business to demonstrate that a Reinsurer assumes significant insurance risk and that they have reasonable chance at experiencing a significant loss Significant is not defined but the standard rule of thumb became the 10/10 Rule which is that the Reinsurer has at least a 10 percent chance of sustaining a 10 percent or greater loss Does not apply to life covers However, if such a rule were applied to a health capital relief cover, credit for reinsurance would still be granted because the type of cover is a quota share and the Reinsurer participates in first dollar losses 21

46 Recap Reinsurance for capital management purposes is a powerful tool. It: Boosts a products return Increases the Cedant s RBC ratio Meets credit for reinsurance requirements Most importantly, it: Reduces the Cedant s required capital while still allowing the Cedant to 1) retain all of the profits on the business, in excess of the Risk Charge, and 2) Retain all of the assets backing the reinsured business 22

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