Pricing and Reserving Long Term Health Insurance in the German Model

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1 The Actuarial Society of Hong Kong Pricing and Reserving Long Term Health Insurance in the German Model Irene Shepp Hong Kong, March 8 th 2013

2 Agenda German Health Insurance System Private Health Insurance Products Pricing Reserving Monitoring Healthcare Reforms in Germany 2

3 German Health Insurance System German Health Insurance System Private health insurance (PHI) Public health insurance (SHI) 3

4 German Health Insurance System Sneak peak into the SHI Members in the public scheme (split 2010, see graph*) Employees with a pre-tax income not exceeding 4,350 EUR per month (statutory health insurance limit in 2013) Civil servants, self-employed need to purchase private health insurance protection Spouse and children with low income are covered if the main breadwinner is covered no extra premium charge required Pensioners Voluntary insureds (income > statutory insurance limit ) *source: as of

5 German Health Insurance System Sneak peak into the SHI Premium/Contribution is set by Federal Ministry of Health In % of salary/pension (average 15.5% in 2013), split between Employee (8.2%) and Employer (7.3%) or Pensioners (8.2%) and Pension insurance carrier (7.3%) Up to a limit ( contribution ceiling ) 3, EUR/month in 2013 Resulting in a premium cap of 610 EUR/month Independent of gender, age, occupation or medical history Problem: demographic development 5

6 German Health Insurance System Sneak peak into the SHI Benefits Wide range: outpatient/inpatient medical treatment, drugs, remedies, aids, sickness leave benefits, dental care Basically free choice of physicians and hospitals Directly paid from insurance company to physician/hospital Problem: frequency of visits and possibly incorrect billing *source: as of

7 German Health Insurance System Sneak peak into the SHI Benefits for single service areas, SHI 2011, in percentage (3) medical treatment (2) drugs other home health care Preventive care and rehabilitation pregnancy/maternity transport costs (4) sickness payment Medical equipment Remedies (5) Dental treatment Dental prostheses Social service, prevention (1) hospital treatment Early diagnosis Source: GKV Spitzenverband

8 German Health Insurance System Private versus Statutory Statutory health insurance (SHI) 146 Carriers 1 in 2011 Members (in mio., incl. Pensioners) Revenues (in bn EUR) Private health insurance (PHI) 43 Carriers 3 in 2011 Members (in mio.) (comprehensively insured) 41.1 (all, incl. supplemental policies) Revenues (in bn EUR) (comprehensively insured) 34.7 (all, incl. supplemental policies) Members Source: Federal Ministry Health, January Source: Federal Ministry Health, September Source: PKV Association, financial report 2011/2012 8

9 Agenda German Health Insurance System Private Health Insurance Products Pricing Reserving Monitoring Healthcare Reforms in Germany 9

10 PHI: Types of insurance *Full (comprehensive) health insurance coverage Members: employees with an income > statutory insurance limit, civil servants, selfemployed Typical benefits: hospitalization benefits and outpatient medical treatment; and often dental care benefits *Long-term care insurance (LTC) For PHI members with full insurance coverage PHI wide: standardized pricing **Additional insurance Insurance cover additional to SHI Insurance for outpatient benefits (e.g. financial benefits for medication) Insurance for (elective) hospital benefits (e.g. 2-bed room) Dental care insurance Daily (or daily hospital) benefit insurance insurance cover additional to LTC **Special forms of insurance Foreign travel health insurance, Segmental insurances (e.g. eyeglass insurance) * Similar to Life- Techniques ** both: Similar to Life- or NonLife- Techniques 10

11 PHI: Types of insurance Revenue 2011 (34.7 bn EUR in total) Source: PKV, financial report for private healthcare insurance 2011/

12 PHI - Full health insurance coverage Framework Now we focus on: full health insurance coverage Several parties involved Free choice Policyholder Bill Hospital /Physician Benefit: Reimbursement Cost regulation (fee scale, ) Contract PKV carrier Strong influence - new business - health costs Government Source: Gen Re

13 PHI - Full health insurance coverage Regulation Government fee scale ( GOÄ ) for doctors for patient treatment Fixed billing rates for medical services Factor 1-3.5*, according to the level of severity, e.g. personal performance for physicians Factor 1 similar to SHI level Factor >1-2.3 standard in PHI Factor > with written explanation Factor >3.5 agreement with the policyholder, in advance for hospital benefits e.g. elective hospital benefits Treatment from head/chief physician: Factor 3.5 Treatment from representative physician: Factor 2.3 Government fee scale ( GOZ ) for dentists Cost limitations for drugs Introduction of manufacturer discounts in 2011, similar to SHI Reduction of pharmacies margins * source: PHI Association, Die Gebührenordnung für Ärzte 13

14 Agenda German Health Insurance System Private Health Insurance Products Products, similar to Life-Techniques Pricing Reserving Monitoring Healthcare Reforms in Germany 14

15 Pricing Underwriting Individual risk assessment (Underwriting questionnaire) Time frame (history) #Carrier: Hospital treatment/ surgery -> all: 5 or 10 years Outpatient treatment -> most: 3, some: 5 years Dental treatment -> most: current, some: 3 or 5 years Illnesses/ Accident -> some: current or 3 or 5 years, 1: 10 years Drugs -> some: current or 1 or 3 years, few: 5 years Addiction (Sucht) -> some: 3, 5 or 10 years Psychotherapy -> some 5 or 10 years Source: Morgen & Morgen, Abfragezeiträume KV bei Gesundheitsfragen, Stand Report of medical examination 15

16 Pricing Underwriting Rating factors (Gender, until 2012) Age Medical history Acceptance (under normal conditions) Risk loading for a known illness Exclusion of benefits (infrequently) for a known illness Rejection (e.g. chronic disease) (Occupation, for daily sickness benefit only) 16

17 Pricing Principles Pricing principles Products/Tariffs Minimum: hospitalization and outpatient benefits, often: dental care included Companies typically have split the coverage in different tariffs => a lot of combinations are offered, Policyholder can choose the coverage Individual risk assessment at the beginning Life-long insurance cover period Contract with the policyholder can not be cancelled by PHI Benefits can not be reduced by PHI Level premium & medical inflation => premium adjustment mechanism 17

18 Pricing Principles > Level premium: The premium rates do not increase because of increasing age. Accordingly a reserve (provision for increasing age) is built up. > Equivalence principle: the present value (PV) of benefits equals the PV of premiums. at beginning of the insurance contract valid for insured collective not for individual policyholder Collective: per Tariff, (gender,) group males, females, teenager & children claims Level premium 18

19 Pricing Actuarial Assumptions For full health insurance coverage - similar to life techniques (source: Regulation about actuarial methodologies for pricing and reserving in the PHI, KalV) > Interest rate ( 3,5%) > Decrement tables (mortality, lapse) > Claims per person ( Kopfschäden ) > Security loading > Other loadings > Other (e.g. daily cash insurance) Duration of illness, days of benefits, amount of days with hospital / long-term care, frequencies of hospital or LTC benefits, 19

20 Pricing Actuarial Assumptions > Claims per person (K x ): typically divided in Claim level (basis level): G =K 43 Age-dependency: k x =K x /G Gender specific costs (pregnancy, maternity) have to be allocated Depending on tariff, age, (gender, until 2012) Source: BaFin, incidences rates 2011 in PKV, 19. December

21 Pricing Actuarial Assumptions Source: BaFin, incidences rates 2011 in PKV, 19. December

22 Pricing Actuarial Assumptions > Mortality rate: q x BaFin statistics (or own portfolio analysis) (gender, until 2012) and age-dependency Source: BaFin, PKV mortality rates for males, 2009 /

23 Pricing Actuarial Assumptions Lapse rates w x own portfolio analysis (or BaFin statistics) tariff, (gender, until 2012) and age-dependency since 2009 divided in two parts: PHI lapse rate 2011: SHI lapse rate 2011: age Source: BaFin, incidences rate in PKV, 19. December 2012, other benefits, males 2011 age 23

24 Pricing Actuarial Assumptions > Surrender value Transfer to SHI => no surrender value current reserve is a surplus to the collective group Since 1st January 2009: new Tariff generation, so that transfer to other PHI company =>reduced surrender value current reserve reduced to SHI-level (compared to Basis Tariff) Remaining part is a surplus to the collective group Problem: Individual risk assessment at new company risk loading possible 24

25 Pricing Actuarial Assumptions Interest rate approach No guarantee as in Life Limit (maximum) = 3,5% No issue in the past Portfolio yield = 7.2% in 2000* Portfolio yield = 4.3% in 2010 *? source: Gen Re 2013 source: Gen Re 2013 * source: lower house of German Parliament, DS17/9330, : Minimum (AUZ, 3.5%), AUZ: actuarial interest rate, company specific Yearly forecast: which minimum interest rate can be achieved within one year? Existing portfolio Current average interest rate Capital investment AUZ source: Gen Re 2013 new portfolio Market interest rate 25

26 Pricing Actuarial Assumptions Security loading Implicitly included in each actuarial assumption Explicitly 5-10% premium added Other loadings (expenses) Profit participation At least 90% of investment profit earned on reserves Reserve increase for a later balancing effect on premium adjustment At least 80% of profit => policyholder Lower premium adjustment or cash distribution Acquisition costs, claims handling expenses, administration costs, Loading for cost allocation in special tariffs (standard tariff, basis tariff) 26

27 Pricing - formulas Yearly net premium: P x = A x / ä x with present value of an annuity: ä x = with present value of benefits: Ax = K x+t : expected yearly benefits of an insured, age: x+t years ϖ x t= 0 ϖ x t= 0 K D x / D x+ t with Dx = l x * v x and v = 1 / (1+i), i: interest rate with decrement l x+1 = l x * (1 q x s x ), q x : mortality rate at age x s x : lapse rate at age x Tariff switch PKV -> GKV Tarif switch PKV( A ) -> PKV( B ) + t D x+ t x / D x 27

28 Agenda German Health Insurance System Private Health Insurance Products Products, similar to Life-Techniques Pricing Reserving Monitoring Healthcare Reforms in Germany 28

29 Reserving Reserve (Provision) for increasing age Formula: m V x = A x+m P x * ä x+m Actuarial assumptions: the same as for pricing New business: sufficient value for each insured policyholder In case of known medical history (information from risk assessment), additional charge for higher risk is demanded. Business in force: sufficient expected value for the insured portfolio (for collective only) Not for an individual insured policyholder 29

30 Reserving Components of Level Premium Risk premium Saving contribution for Reserve Lapse effect: free reserve => surplus for portfolio dead policyholder switch from PHI to SHI Claims Reserve IBNR, incurred but not reported 30

31 Agenda German Health Insurance System Private Health Insurance Products Products, similar to Life-Techniques Pricing Reserving Monitoring Healthcare Reforms in Germany 31

32 Monitoring Claims > Medical inflation Taken into account, but only for a limited duration Trigger for premium adjustment Medical treatment normalized 2001 SHI Medication /dressings Dental treatment / prosthesis PHI outpatient treatment > Over all benefit areas* PHI, : +3.2% SHI, : +2.2% hospital services *Source: PKV, financial report for private healthcare insurance 2011/2012 inpatient treatment 32

33 Monitoring Claims Monitoring (source: KalV, Regulation about actuarial methodologies for pricing and reserving in the PHI) Claims analysis Minimum: yearly basis per Tariff, (gender,) group males, females, teenager & children Analyze incurred claim level (K 43 ), last 3 years Confine claims and portfolio to observation period, each year Inc. Inc. Inc. extrapolate Incurred expected month 2014 Comparison > (5-)10% changes Check all actuarial assumptions Adjust premiums, if necessary 33

34 Monitoring Mortality Monitoring (source: KalV, Regulation about actuarial methodologies for pricing and reserving in the PKV) Mortality analysis (introduction 2009) Minimum: yearly basis per Tariff, (gender,) group males, females, teenager & children Analyse the ratio of present values of benefits per age-range 21-45, 46-70, required : interest rate and claims as expected, mortality rate as currently published (by BaFin) expected : interest rate, claims and mortality rate as expected Calculate the arithmetic average of ratios per age-range Result: maximum of arithmetic averages In case of result > 5% Check all actuarial assumptions Adjust premiums, if necessary 34

35 PHI: similar to Non-Life Techniques short introduction > Product-Features of non-slt Business Defined benefit catalogue Limited / unlimited insurance cover period Limited: short-term/long-term duration With / without premium adjustment clause With / without ordinary right of cancellation for insurer With / without contract duration extension Less regulations (compared to SLT business) No profit participation mandatory Example: Foreign Travel Insurance (not comprehensive) Cover period one year, with contract extension, with ordinary right of cancellation for insurer, without premium adjustment 35

36 Agenda German Health Insurance System Private Health Insurance Products Products, similar to Life-Techniques Pricing Reserving Monitoring Healthcare Reforms in Germany 36

37 Health care reforms Introduction +10% premium (extra charge) as of 2000 Payable from each policyholder of comprehensive insurance cover, age: years for reduction of future premium adjustments, age 65+ Sharp increase of the statutory insurance limit in 2003 > 3-year waiting period for employees who want to enter PHI as of 2007 continuously for 3 years: Income > statutory insurance limit In force prior to 2011 Allgemeines Gleichbehandlungsgesetz (AGG) as of 2008 Costs for pregnancy /maternity are allocated to female and male insured Competition reinforcement law (GKV-WSG) as of 2009 Introduction of compulsory insurance thousands of people who were not insured enrolled into PHI Introduction compulsory insurance & basic Tariff ( Basis-Tarif ) Surrender value in case of Tariff Switch within PHI insurer New Tariff Generation for new business EU wide: Introduction of unisex tariffs in 2012 New Tariff Generation for new business 37

38 Basic ( Basis ) Tariff Introduction in 2009 With introduction of compulsory insurance PHI-wide and uniform basic tariff Coverage is defined by SHI scheme Changes in SHI will change the coverage Contribution is risk-oriented by age (and gender until 2012) No risk assessment, no risk loadings Limited to highest SHI-contribution Subsidized by all other PHI insured Source: PHI Association, financial report 2011/2012 Benchmark for surrender value in case of PHI switch 38

39 Links & Sources Links: BaFin: Federal Financial Supervisory Authority, Bundesministerium für Gesundheit: Federal Ministry of Health, GDV: German Insurance Association, GKV: statutory health insurance GKV Spitzenverband: National Association of Statutory Health Insurance Funds, PKV: private heath insurance PKV-Verband: Association of German private healthcare insurers, Sources: Klaus Bohn, Die Mathematik der deutschen Privaten Krankenversicherung, 1980 Hartmut Milbrodt und Tobias Kniep, Aktuarielle Methoden der deutschen Privaten Krankenversicherung, 2005 Erich Schneider, The Main Features of German Private Health Insurance, Trans 27 th ICA 39

40 Disclaimer This presentation is protected by copyright. All the information contained in it has been very carefully researched and compiled to the best of our knowledge. Nevertheless, no responsibility is accepted for its accuracy, completeness or currency. In particular, this information does not constitute legal advice and cannot serve as a substitute for such advice. It may not be duplicated or forwarded without the prior consent of the Gen Re. Diese Präsentation ist urheberrechtlich geschützt. Alle hierin enthaltenen Informationen sind sehr sorgfältig recherchiert und nach unserem besten Wissen zusammengestellt. Dennoch können wir keine Haftung hinsichtlich ihrer Genauigkeit, Vollständigkeit oder Aktualität übernehmen. Insbesondere stellen diese Informationen keine Rechtsberatung dar und können auch nicht als Ersatz für eine solche Beratung dienen. Eine Vervielfältigung oder Weiterleitung ist nur mit vorheriger Zustimmung der Gen Re gestattet. 40

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