Webinar Transcript: Key Components of the Health Insurance Rating Process.

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1 Webinar Transcript: Key Components of the Health Insurance Rating Process. Ken Frino Group Vice President, JOHN WEBER: I m John Weber with the A.M. Best Company. Welcome to our webinar, Key Components of the Health Insurance Rating Process. This webinar is being presented exclusively for the members of the National Alliance of State Health Cooperatives. A.M. Best group vice president Ken Frino and assistant vice president Sally Rosen will give a detailed overview of the ratings process. We would like to thank NASHCO for their assistance in providing this webinar to its members and for your participation. We may mention the subject of financial strength ratings. A full explanation of A.M. Best s ratings is available online at KEN FRINO: We re glad that we re here today to go through the key components of the health insurance rating process. I m going to hand it off to Sally in a few minutes and she ll take you through the components of our rating process. SALLY ROSEN: We re going to start with the main components that we look at as part of the rating process. There s three main parts that we look at: balance sheet strength, operating performance, and business profile. We re going to start with balance sheet strength. We look at the capitalization of a company; its liquidity, both current and overall; investment portfolio; underwriting leverage; equity per member per month; and debt within the organization. We re going to begin with capitalization. We look at the level of capital adequacy. When we talk about capital adequacy, we re looking at both risk based capital as well as A.M. Best s own capital adequacy ratio, our own internal capital model. We look at historical levels and trends as well as both projected RBC as well as our own projected internal model. Sally Rosen Assistant Vice President, We look at the availability of capital support. Are there potential external sources of capital should it be needed within the insurance entity? We look at the potential for dividend policies. Does the entity has a history of paying dividends, or is there potential that the insurance company will pay a dividend to a parent company? FRINO: Just to give you some background in terms of the data that we re using, the measures that we re looking at here, the basis for these calculations and the information we re looking at is the statutory filings of the operating entities. As Sally goes through some of these measures, there may be references to GAAP type measures. She ll point that out as she goes through. I want to make it clear that the starting point for our analysis of the balance sheet is the statutory filings of the entity. ROSEN: We discuss with a company their investment portfolio. What is their investment strategy? Given the short term nature of health insurance claims, health insurers tend to have more conservative portfolios. We discuss with a company the distribution of their invested assets. How often are investments reviewed for impairment and what are the guidelines to impair an asset? Is the portfolio managed internally, or do you utilize an external manager? If so, what external manager are you using, and what sort of level of interaction is there between the company and an external manager? We ask for a copy of an investment watch list for any investments that might be being monitored for potential impairment. We ask for a copy of the investment portfolio, during which we discuss with a company if the current allocation in line with their investment policy? If it s not, why? 1

2 Sometimes it s because they re in the middle of revising the policy. Or it could just be temporarily out of sync. We also discuss with a company any potential changes that may be made to the investment strategy. We look at liquidity. We look at both ratios for current liquidity and overall liquidity. We look at the trends in liquidity, historical trends. We look at underwriting leverage, the ratio of net premiums written to capital and surplus. We look at the level of equity per member per month. We look at whether the organization uses reinsurance, and if so, what carriers are they utilizing, and for how much? Is it for catastrophic risk, and what is the organization s maximum retention level? FRINO: Just to emphasize what we look at in terms of balance sheet strength, for companies that are established, we have information that goes back several years. Typically, we look at five years. We rely on companies providing us with information in the years going out in terms of projections and pro formas. For start up companies, we typically look at, at least, three years worth of pro forma information. Then we run our calculations and look at the data based on that information provided to us by the company. ROSEN: We look at if there s any debt in the organization, the type of debt that has been issued, the terms and the covenants. We also look at the financial leverage and the interest coverage. Guidelines for financial leverage and interest coverage are listed in A.M. Best criteria, insurance holding company and debt ratings. Although it should be noted that typically interest coverage tends to be stronger than the minimum stated in the criteria for health insurance companies. Typically, health insurers tend to have stronger RORs (Return on Revenue) than some of the other types of insurance companies such as life companies. What we have in the next two slides is a compilation of all health insurance rated entities from A.M. Best s population. We have here a compilation of RBC, net premiums written to total capital, equity per member per month, current liquidity, and overall liquidity. It should be noted that these are all entities that we rate, which may include some smaller entities within a larger rating group. They can somewhat skew numbers within a rating level. It should also be noted that there are only a few ratings at the highest level and at the lowest level as well. This is the second slide with the second level of ratings. Next, we look at operating performance. There s a list of metrics here that we look at: earnings trends, return on revenues, loss ratios, administrative expense ratios. Keep in mind that we look at the trends. Have the trends been favorable? If there s a change in trends, why? The analytical team is trying to get the story behind the numbers. This is both historical and going forward. If there s a change in the numbers, we would like to know why so we can accurately come in and explain it in house. We look at projections. We look at profitability. Is it being driven by underwriting? Is it being driven by investment income? Is there initial costs such as start up costs involved in some of the operating results? We look at the return on revenues and its trends. We also look at the sustainability and the volatility of earnings. If it s been very strong for a very long period, how sustainable is that going forward, given the changing environment that we re under? We also look at the regulatory environment and the rate review process. With earnings sustainability, we look at a company s pricing discipline and its For start up companies, we typically look at three years worth of pro forma information Ken Frino strategy. Are they in a growth mode? Are they willing to hold their ground in their pricing and not adjust their pricing to gain or keep an account? Or are they in a mode where they re trying to grow and they re willing to make some concessions in order to retain or grow their business? We look at the competitive market and how that plays into the growth strategy. We look at a company s minimum loss ratio requirement now that we re in a world of minimum medical loss ratios. Whether the company is pricing to meet the minimum, or are they pricing at maybe slightly below the minimum and they re willing to pay rebates? We look at regulatory mandates and the regulatory environment and the company s ability to get rate increases approved by the regulator. We look at any shifts that may be occurring in the business mix, any shifts to or from government programs. That does affect operating margins. We also look at shifts away either from or to a specific line of business. We would like to know the reasoning behind those shifts. We have a discussion about medical cost control and trends. If there s a spike in trends, is it expected? We ve had a few years of trends running below normal. What is the company s ability to capture the shift in trends? When are they expecting an uptick in trends to occur? We also talk to companies about administrative efficiencies, economies of scale, and IT infrastructure. Do they have infrastructure necessary for the growth that s going to be seen coming with the exchanges as well as for ICD 10 and other changes coming up. We look at a company s product mix. How much of their business is commercial? Within the commercial, we 2

3 look at the group ASO versus risk, keeping in mind we do understand that ASO business is lower margin business. As well as in the risk, are there certain segments, individual, small group, or large group that you re targeting? We also look at whether a company is involved in government programs such as Medicaid Managed Care or Medicare Advantage or Medicare Supplement. Typically we do understand that government business is lower margin. We re also going to look at what you re relying on for profitability. Is a company relying on government programs for profitability, given that government funding can change? Also, we ask if there s any non insurance operations and, if applicable, are they in the insurance entity, or are they perhaps in a sister entity that is non regulated by a state insurance department? We also ask for results by product line, including historical, current year, as well as projected and loss ratio by line. What we re looking for there is to see if there s a certain product line that s carrying profitability. If there s a shift in profitability among product lines, why? And going forward, where does the company see itself and their profitability in the future. We also look at reserves and we ask to discuss the methodologies that are used. For margins, is there any margins built into the reserves, either explicit or implicit. Again, just as on the balance sheet side, we do have some of our key metrics for the operating performance. The return on revenue, loss ratio, expense ratio, and combined ratio, again keeping in mind that these are all entities that we rate which could be many entities within a rated group. That can somewhat skew some of the individual numbers. We have a discussion with the company on its business profile. We talk to them about their operating environment. Geographic reach, is it limited or expansive? Limited can be a single state. It can be a portion of a state, whether it be select counties or certain metropolitan areas within a state. Or are they multistate? What are the economic conditions given in a state? Demographics within their operating market. Obviously, as individuals age they re going to age out of commercial insurance and into Medicare. The percentage of the population that s uninsured or unemployed and may not be able to afford coverage, as well as what percentage of the insurable population a company is covering. We also have a discussion about the regulatory climate, the company s relationship with its regulators. Lastly, we have a conversation with a company about its competitive environment, who its main competitors are. Do they see any new entrants into the market, or any changes in the competitive environment in that market? FRINO: I just want to emphasize that the balance sheet and operating performance where we talked about financial measures; you re clearly looking at quantitative measures and an analysis that s focused on the results of the company, as well as projections of the company. When we get to the business profile of the analysis, the management meeting with the company plays a very important role in getting the information necessary to look at the business profile of an organization. As Sally was going through this, you can t get this information off the financial statements that are provided to us. Some of it, but a majority of it is just through a conversation with the company. We get this updated annually. We also reach out to companies more frequently as we need to get an update on the environment, as well as what s going on in the markets that they re competing in. The qualitative part of the meeting is very important. It s getting the story. It s understanding your organization, the story behind the numbers Sally Rosen As Sally continues, the qualitative nature of our analysis really comes into play with the business profile. This is where we drill down. Can the company sustain its profitability and grow its capital? Business profile plays an important role in a company being able to do that. ROSEN: This is all information we re looking to gain from the company from our interactive meetings with a company and their senior management team. We had discussions about growth trend. Historical, has it been through acquisition or has it been organic? What have been the source of growth? Obviously given the economy and layoffs over the last few years and the rise in unemployment, what has been the impact of in group losses? We look at the future growth trends: where do you think your growth is coming from? We look at product diversity and business mix. When we look at product diversity, we re looking at it among both health as well as whether there s other ancillary lines that either you re offering as a carrier or you re partnering with someone to offer. We also look at products within the health base. Are you just offering individual? Are you offering individual, small group, large group? Are you offering self-funded, ASO (Administrative Services Only)? What kind of products are you offering, and what is the business mix or expected business mix among the premiums and the revenue streams? We also look at concentration risks whether it s one account that represents a sizeable amount of premium or revenues, whether it s a particular product that is driving it, or a broker or a distribution source that is bringing in most of your revenues. 3

4 Geographic concentration risk, having business in a single state: if there are many health carriers that operate in a single state environment you are subject to the regulatory environment and the economic environment of a specific state. We also have discussion with companies about their provider relationships. The size of the network, the network reach, the stability of the network, any pricing pressure in that network or in building that network. We also are discussing with companies Accountable Care Organizations or other unique type of provider relationships that the insurance companies are building with provider groups. We have a discussion about distribution. How are your products distributed? Do you utilize internal distribution, external distribution? If it s external, is there any reliance on any particular broker or marketing source? FRINO: I thought it would be important to touch on our ratio. It s very similar to the NAIC. Sally mentioned it earlier when we had some statistics on the capital ratio under the NAIC. We thought it d be good to run through our own model. It looks simple, but there are many components and details that go into this model. Looking at this first slide, it gives you an idea of the different pieces. As I said earlier, it follows closely the NAIC s RBC model. I m going to take a little bit deeper dive into the sections within our capital model. For health companies, the risk that we really focus in on is the section C 2. Typically, a health company will not have very risky investments and are not relying on investment income for their profitability. It s usually very liquid, shortterm in nature. We don t typically see a heavy amount or a lot of risk there in the C 1. The next slide gives a bit more detail on our C 2, looking at the different risk factors that are assigned to the different lines of business. The first part is the individual accident and health and the different lines of business and risk charges that are assigned to those lines of business. As you continue down the page, there s a section on the group accident and health, again showing the risk charges by line of business. I want to give an idea for the risk charges under our BCAR model. All this information is out on our website in our criteria and methodology section. Another area that I wanted to emphasize is the C 4 business risk. Again, there s a risk charge there for accident and health premiums, to show you where some of the areas that could impact a health company s ratio. Moving to the next chart on this page, the adjusted capital and surplus chart, is a breakdown of what we determine as being the adjusted capital and surplus and the different components that make that up. The factors we use in terms of RBC to determine adjusted capital and surplus. Make note of how we treat surplus notes. It s different than what you would see under the NAIC. This caption here is from our methodology that explains it and how we treat surplus notes under our model. That s an overview of the BCAR. I thought it would be important to jump back to some financial measures and one of the tools that we use in determine a company s rating. Sally and I will talk about the rating meeting itself. We touched on both the quantitative and qualitative nature of our analysis and we talked about business profile. The rating meetings are very important in terms of filling in some of those buckets or the information that we need to craft and to develop our rating recommendation. There s quite a bit of work that s done to prepare for the rating meeting. The analytical team works very closely with the rated entity to develop an agenda and a list of items that we want to make sure that we cover during our meetings with you. Obviously a substantial portion of the meeting is to review and go over the financial results as well as the financial projections, your business plans in terms of top line growth as well as expected returns on the business. Sally mentioned provider networks, the competitors in that marketplace, where you see yourself in terms of some of the challenges within your marketplace that are important. Participants from the company that typically discuss this with us start with the CEO and president of a company, CFO, treasurer, chief underwriting officer, actuarial group, all those individuals that have a prepared presentation. We go through all those items. We meet annually with companies. But we are in contact with companies throughout the year and leading up to the annual update of their rating. ROSEN: The qualitative part of the meeting is very important. It s getting the story. It s understanding your organization, understanding the story behind the numbers. We can look at the numbers and see how the earnings are going and we can look at the projections and see how the earnings are trending the growth that is being projected. But it s understanding the why and the reasoning behind it that is very important as part of the rating process. FRINO: The meetings are usually a full day. It varies, depending on the operations of the company and the complexity of the organization. We re usually on site. Occasionally we ll have meetings here in our home office. It s a team usually of two individuals, a manager and an analyst. They usually spend the full day with the company. Obviously, it depends on the size and complexity of their organization. After the meeting, we compile all the information. We look at our notes as well as the information presented to us. The analyst begins to put together their recommendation for the company. Quite a bit of follow up information may be required from the company. We cover many things at the rating meeting but there are certain things that just aren t available at the time. We ll send follow up requests to the company asking for some items that are necessary for us to do the rating. There s time that s required to develop that 4

5 information. That information is incorporated in the recommendation to our rating committee. Once that s complete, it s moving on to our rating committee. We schedule a meeting with the rating committee about eight weeks after the management meeting. At that time the recommendation is presented to committee. The analyst makes that presentation. The rating committee is usually seven people. We ll listen to the recommendation and then ask questions, comment on that recommendation. That leads to a vote on the recommendation itself, concluding on the rating for that entity or the entities within that company or group. Once that s complete, next we move on to communication to the company. When we communicate the rating decision to the company, it s just not letting them know what that letter rating is. It s letting them know the rationale behind our decision and how we concluded on that. It s going to include both positives and negatives of where we see some of the challenges, as well as where we see some of the advantages and the positives that the company has exhibited both historically and going forward. It s a very comprehensive review of the entity, taking both the financial information and the qualitative information and putting that together. Then we reach our conclusion and have that discussion with the company. ROSEN: After the rating committee meets there is a conversation with the rating contact at the company. Nothing is released publicly without the company reviewing it first. We do not release the rating. We do not release the report or the rationale until it has been reviewed by the company and, if it is an initial rating, until it has been accepted by the company. FRINO: That takes you through the rating meeting, the rating committee, and the communication to the company. That s the whole process. Sally walked you through how we rate insurance companies, health insurance companies, and the key components. Then we backed it up a little bit to say OK, what takes place first? That would be the meeting with management. Then we just took you through the meeting, the rating committee, as well as the communication of the final rating decision at our committee process. WEBER: Ken and Sally, would you like to address what the options are available to companies once they receive their letter grade? FRINO: Beginning with our final decision, the company can have three options. One, they can accept the rating. Then we move to public dissemination of that rating through either a press release or other means. The company could reject it. The third option is that the company could appeal it. It s then up to the chair of the rating committee to review the appeal and, if there s material new information, whether or not that should be reviewed at a committee. There are three options: accept, reject, or appeal. ROSEN: It should be noted that if a rating is rejected, the information is not released publicly and it remains confidential. FRINO: I guess just to we touched on it earlier in terms of new companies versus companies that we have established ratings with. With new companies, we re looking at the company s plans and at least three years to five years of information. We have criteria methodology on our website that has the details regarding new companies and startups. Becase it s a new company the annual meeting is usually somewhat longer than with some of our more established companies. We re getting quite a bit of information from these new companies in terms of their business plan and strategy, as well as their financial projections, where they see themselves growing and as they re developing their business plans, where they see their key strengths in terms of being able to achieve their growth targets as well as the bottom line results of the companies. For new companies, we look at where is the initial funding coming from in terms of the capital and surplus and how are they going to support their growth going forward. Is it through profitable earnings and slowly building capital and surplus? Is there a holding company that has access to funds that will help push down capital into the entities so support that growth? Is it an individual? Could it be somewhat private equity? We want to know the ownership structure and how they re going to be able to support their growth going forward. That s why the initial meeting is quite detailed in terms of getting to that information, because we don t have the history with the company. We re trying to get more information about the background of the company, as well as where they re going to be positioned in the next couple of years. We have a methodology for start up companies and what s required of them. You would find that very helpful if you go to our website and take a look at that. WEBER: Ken, Sally, it has been a very comprehensive and informative presentation. Thank you so much. We d like to remind our participants that for additional information they can contact Alan Kandel, Business Development Manager at , extension 5036, or by at We d like to thank NASHCO for their assistance in providing this webinar to its members and for your participation. For the A.M. Best company, I m John Weber. 5

6 The Financial Strength Rating opinion addresses the relative ability of an insurer to meet its ongoing insurance obligations. The ratings are not assigned to specific insurance policies or contracts and do not address any other risk, including, but not limited to, an insurer s claims-payment policies or procedures; the ability of the insurer to dispute or deny claims payment on grounds of misrepresentation or fraud; or any specific liability contractually borne by the policy or contract holder. A Financial Strength Rating is not a recommendation to purchase, hold or terminate any insurance policy, contract or any other financial obligation issued by an insurer, nor does it address the suitability of any particular policy or contract for a specific purpose or purchaser. In arriving at a rating decision, A.M. Best relies on third-party audited financial data and/or other information provided to it. While this information is believed to be reliable, A.M. Best does not independently verify the accuracy or reliability of the information. For additional details, see A.M. Best s Terms of Use at Copyright 2013 by, Inc. ALL RIGHTS RESERVED. No part of this report or document may be distributed in any electronic form or by any means, or stored in a database or retrieval system, without the prior written permission of the. For additional details, refer to our Terms of Use available at the website: 6

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