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Episode II

Episode II. How To Use AIS’s Directory of Health Plans To Research Health Insurance Companies.

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Episode II

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  1. Episode II How To UseAIS’s Directory of Health PlansTo Research Health Insurance Companies

  2. Hundreds of health plan market analysts, consultants, business partners, vendors, strategists and policymakers use AIS’s Directory of Health Plans to help them accurately evaluate their markets and opportunities.Here’s what you need to know to make this data work for you: • How These Data Are Collected and Verified • What We Mean by “Health Plan Enrollment” • Definitions of Risk Status, Sector and Plan Model • Where to Find What You Need on the CD • How the Spreadsheets Relate to Each Other

  3. Hundreds of health plan market analysts, consultants, business partners, vendors, strategists and policymakers use AIS’s Directory of Health Plans to help them accurately evaluate their markets and opportunities.Here’s what you need to know to make this data work for you: • What We Mean by “Health Plan Enrollment”

  4. What We Mean by “Health Plan Enrollment” AIS counts medical enrollment only — Members or covered lives in primary medical insurance plans that are based on a regional network. Medical enrollment does NOT include: • Pharmacy benefits • Medicare Part D (drug benefit only) • Dental benefits • Vision care, chiropractic or other specialty benefit membership • Non-health membership such as life, stop-loss, workers comp, etc. WHY? • Focusing on primary medical insurance allows us to count each covered — and uninsured — member only once. • This allows the most accurate market share data and enables us to categorize virtually every covered person in the U.S., by state and coverage type. • If we counted specialty benefit members, we would be counting some people more than once, because specialty benefits are typically add-ons to a primary medical insurance policy.

  5. Hundreds of health plan market analysts, consultants, business partners, vendors, strategists and policymakers use AIS’s Directory of Health Plans to help them accurately evaluate their markets and opportunities.Here’s what you need to know to make this data work for you: • How These Data Are Collected and Verified • What We Mean by “Health Plan Enrollment” • Definitions of Risk Status, Sector and Plan Model • Where to Find What You Need on the CD • How the Spreadsheets Relate to Each Other

  6. Hundreds of health plan market analysts, consultants, business partners, vendors, strategists and policymakers use AIS’s Directory of Health Plans to help them accurately evaluate their markets and opportunities.Here’s what you need to know to make this data work for you: • Definitions of Risk Status, Sector and Plan Model

  7. Definitions of Risk Status, Sector and Plan Model Risk Status When a health insurer IS at risk for medical losses, this membership is called Risk-Based, or Fully Insured. The client pays premiums to the insurer, and if the cost of medical claims is more than the amount of premiums collected, the insurer loses money. The insurer spends money every time a member uses covered services. When a health insurer is NOT at risk for medical losses…someone else is — typically an employer/group health sponsor or a government entity. In this case the health plan’s membership is referred to as Non-Risk, or Administrative Services Only (ASO). The client contracts with the insurer to process claims, and pays a flat fee for each claim processed. The insurer does not collect premiums. The insurer makes money every time a member uses covered services.

  8. Definitions of Risk Status, Sector and Plan Model Risk Status It matters because… • WHEN AT RISK, INSURERS • Must ensure that medical costs do not exceed premium revenue • Aggressively manage costs, utilization, reimbursement and benefit design • Buy services and products designed to help them control costs and utilization • WHEN NOT AT RISK, INSURERS • Make money every time a member uses covered services • Are not motivated to manage or control costs or utilization • Buy services and products designed to help them process large volumes of claims efficiently Total Medical Enrollment includes a health plan’s membership in BOTH Risk and Non-Risk plans. You need to determine whether one — or both — of these Risk arrangements is relevant to your desired analysis, based on your goals and product offerings. For instance…

  9. Definitions of Risk Status, Sector and Plan Model Risk Status …If your analysis concerns quality, utilization management or patient satisfaction issues — use RISK membership …If you are a self-insured group shopping for claims processing and administration services — use NON-RISK/ASO membership …If your analysis concerns medical or pharmacy coverage decisions within health plans — use RISK membership …If your goal is sales or service of claims processing systems, office equipment or building services — use TOTAL membership …If your services help payers with benefit design or data analyses —use RISK membership

  10. Definitions of Risk Status, Sector and Plan Model Sector • Private-Sector Health Plans —Are sponsored by Employer Groups or Individual Consumers, including: • - Large, small and mid-sized employers • - Employer unions and industry groups • - Federal Employees Health Benefits Program • - State or county municipal employees groups/unions Public-Sector Health Plans — Are sponsored by a Government Entity as part of an entitlement program, such as:- Medicare Advantage HMOs and PPOs - Medicaid HMOs - State Medicaid agencies - State Children’s Health Insurance plans

  11. Definitions of Risk Status, Sector and Plan Model Sector • Both Private-Sector and Public-Sector plans can be • either Risk-Based or Non-Risk (ASO). • sponsored by a government entity (paid for by tax dollars). The distinction is whether it is an entitlement program or an employee benefit. You need to determine whether one or both of these sectors is relevant to your desired analysis, based on your goals and product offerings.

  12. Definitions of Risk Status, Sector and Plan Model Plan Model Commercial Risk Enrollment is broken down by plan Model — HMO/POS/PPO, etc., where available…

  13. Definitions of Risk Status, Sector and Plan Model Plan Model …but plan model is not always available… In today’s market, when plans are characterized as HMO or PPO or POS it is primarily for marketing purposes — plans with these labels do not necessarily carry the traditional features that once defined these models. There are new and hybrid plan models (and marketing labels) being developed all the time. Many MCOs no longer distinguish membership per these categories. AIS’s Directory of Health Plans tracks ALL health plan enrollment. Our flexible database structure allows us to track marketing and purchasing trends as they evolve.

  14. Hundreds of health plan market analysts, consultants, business partners, vendors, strategists and policymakers use AIS’s Directory of Health Plans to help them accurately evaluate their markets and opportunities.Here’s what you need to know to make this data work for you: • How These Data Are Collected and Verified • What We Mean by “Health Plan Enrollment” • Definitions of Risk Status, Sector and Plan Model • Where to Find What You Need on the CD • How the Spreadsheets Relate to Each Other

  15. Hundreds of health plan market analysts, consultants, business partners, vendors, strategists and policymakers use AIS’s Directory of Health Plans to help them accurately evaluate their markets and opportunities.Here’s what you need to know to make this data work for you: • Where to Find What You Need on the CD

  16. Find What You Need on the CD CD Contents Folders contain the raw data Directory of Health Plans.pdf — is a PDF version of the printed book — easy to search and transport MCOsbyState.pdf — provides the full listing for each plan in each state — easily access all the plans for your state in one place Don’t forget to read FieldLists.pdf and EnrollmentFieldHierarchy.docx to fully understand the meanings of each data field!

  17. Find What You Need on the CD CD Contents 7 valuable workbooks full of data! In familiar Windows file formats — no interface to learn!

  18. Find What You Need on the CD CD Contents In familiar Windows file formats — no interface to learn!

  19. Find What You Need on the CD CD Contents The Mail List workbook has 3 different spreadsheets Read the Introduction tab to learn what each list includes

  20. Find What You Need on the CD CD Contents  …are also included in the full MCO Data Set Health Plan address, phone numbers, fax and website…

  21. Find What You Need on the CD CD Contents …and so are the Key Executives! 

  22. Find What You Need on the CD CD Contents   Two MCO workbooks contain 11 different enrollment worksheets — each featuring a different subset or view of the data

  23. Find What You Need on the CD • MCO Data.xlsx has • National enrollment, broken down by product type • State totals • …Everything you see in the book… CD Contents

  24. Find What You Need on the CD MCO Data.xlsx • Includes these Worksheets: • Health Plans — the full health plan database in a flat file • MCO State Enrollment — state-by-state breakdowns of enrollment estimates for health insurance companies • MCOEnrlRollupbyParent — all enrollment fields, rolled up by parent company where applicable • Commercial Risk — all fields, just for companies that have commercial group risk-based products • Medicare — all fields, just for companies that have Medicare Advantage business • Medicaid — all fields, just for companies that have Medicaid HMOs

  25. Find What You Need on the CD CD Contents MCO Enrollment Breakdowns.xlsx includes ADDITIONALdata from our source material…. 5 Excel worksheets each offer a different subset of enrollment data by state…

  26. Find What You Need on the CD MCO Enrollment Breakdowns.xlsx • Includes these Worksheets: • Commercial — breakdowns by company, by state, of commercial enrollment only • Medicare — breakdowns by company, by state, of Medicare Advantage enrollment only • Medicaid — breakdowns by company, by state, of Managed Medicaid enrollment only • FFS Medicaid — state-sponsored Medicaid enrollment, by state, that is not in HMOs • All — all health plans, with breakdowns by state and sector

  27. Find What You Need on the CD CD Contents Market Share by State   For the MOST accurate, MOST relevant, and MOST comprehensive state-level geographic market share analyses possible

  28. Hundreds of health plan market analysts, consultants, business partners, vendors, strategists and policymakers use AIS’s Directory of Health Plans to help them accurately evaluate their markets and opportunities.Here’s what you need to know to make this data work for you: • How These Data Are Collected and Verified • What We Mean by “Health Plan Enrollment” • Definitions of Risk Status, Sector and Plan Model • Where to Find What You Need on the CD • How the Spreadsheets Relate to Each Other

  29. Hundreds of health plan market analysts, consultants, business partners, vendors, strategists and policymakers use AIS’s Directory of Health Plans to help them accurately evaluate their markets and opportunities.Here’s what you need to know to make this data work for you: • How the Spreadsheets Relate to Each Other

  30. How the Spreadsheets Relate to Each Other  This document shows you which enrollment fields add up to which…

  31. How the Spreadsheets Relate to Each Other The CD contains everything you or your IT department need to know to link the tables when you import them into any software.    See the following slide for the database schema….

  32. How the Spreadsheets Relate to Each Other MCO ID Number is the unique identifier to link MCOs to child records.

  33. Hundreds of health plan market analysts, consultants, business partners, vendors, strategists and policymakers use AIS’s Directory of Health Plans to help them accurately evaluate their markets and opportunities.Here’s what you need to know to make this data work for you: • How These Data Are Collected and Verified • What We Mean by “Health Plan Enrollment” • Definitions of Risk Status, Sector and Plan Model • Where to Find What You Need on the CD • How the Spreadsheets Relate to Each Other

  34. Hundreds of health plan market analysts, consultants, business partners, vendors, strategists and policymakers use AIS’s Directory of Health Plans to help them accurately evaluate their markets and opportunities.Here’s what you need to know to make this data work for you: • How These Data Are Collected and Verified

  35. How These Data Are Collected and Verified • Understanding our methodology helps you • Use AIS’s enrollment data with confidence • Compare AIS’s enrollment data to other sources you may be using • Design your market analyses appropriately AIS’s Directory of Health Plans is the foremost authority on health plan enrollment statistics

  36. How These Data Are Collected and Verified Q: How Can AIS Get Such Comprehensive Participation from Health Plans? Methodology: All known health insurers and PPO networks operating as of Jan. 1 believed to fit the criteria of the database are included. Inclusion is not optional. Companies are surveyed by AIS staff between Oct. 1 and Dec. 31of the year preceding the date of the Directory. AIS researchers are specially trained to understand enrollment terminology and how membership is counted by plans. Each organization is contacted and offered options to fill out an online or paper form, or to provide information via email, fax, mail or via telephone interview. Data provided directly by companies is deemed the most accurate and up-to-date information. For companies that do not return a survey, or where blanks are left on responses, researchers endeavor to complete the record through other means. Survey data is audited against public records as available. Fully insured commercial HMO enrollment is audited against state insurance department filings. Medicare enrollment is audited against Centers for Medicare and Medicaid Services (CMS) records. Medicaid enrollment is verified with state Medicaid agencies. Records are supplemented by data from company websites, SEC filings, press releases and news reports. A: As the publishers of Health Plan Week, and many other long-running, highly respected industry publications, AIS has established relationships with all the major health insurers. Additionally, AIS’s Directory of Health Plans is the official directory resource of America’s Health Insurance Plans (AHIP), the trade association representing health insurance companies. AIS’s Directory of Health Plans is the foremost authority on health plan enrollment statistics

  37. Ready to Order AIS’s Directory of Health Plans? Order Via Our Website at http://aishealth.com/marketplace/aiss-directory-health-plans Or call Customer Service at (800) 521-4323 • Still Have Questions? • Our Customer Service Representatives will gladly put you in touch with our technical editors to make sure you have a full understanding of the database and how to apply it to your specific projects. Call us! • View Episode 1 for more information about what is included in AIS’s Directory of Health Plans. • View Episode 3 if you don’t know whether to purchase the book OR the CD. • View Episode 4 for more information about using the contact data and mailing lists.

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