The Health Cost Guidelines–Commercial include the Commercial Rating Structures, Commercial Area Factors, Commercial Claim Probability Distributions, Managed Care Rating Model (MCRM), and Prescription Drug Rating Model (RxRM).

The Rating Structures are used to determine utilization, charge levels, and claim costs for various health benefits. The Area Factors are used with the Rating Structures to geographically adjust national average costs. Claims Probability Distributions help assess value of deductibles, out-of-pocket maximums, and the effect of plan maximums and area factors by deductible level. The two rating models automate the input and calculation of many of the rating variables and worksheets described in the managed care and prescription drug rating structures.

The Health Cost Guidelines—Ages 65 and Over are used to adjust national average costs to specific geographic areas and to rate Medicare Advantage, Medicare Supplement, and retiree medical plans. They provide a basis for calculating prescription drug claim costs and allow for modifying costs based on age/gender mix, geographic area, trends, and other rating factors.

The Dental Cost Guidelines allow you to:

• Evaluate utilization, average charges, and cost sharing for a variety of plan designs
• Access pricing details specific to orthodontia
• Reflect a fee schedule adjusted by dental procedure code
• Evaluate many cost-sharing alternatives or benefit-specific limits
• Simplify claim cost development and enhance plan rating

Anticipate future claim levels, evaluate historical data, and establish relationships between health coverage levels using the Milliman Health Cost Guidelines—Reinsurance. These guidelines contain rating structures for reinsurance used with fee-for-service or managed care plans provided to commercial or Medicare enrollees.

Analyze and benchmark utilization and costs using the Health Cost Guidelines—Grouper, software which sorts medical and pharmacy claims data into hospital, surgical, medical, and other benefit service categories using Health Cost Guidelines (HCG) definitions.

Determine claim costs for a wide variety of prescription drug benefit plans for either commercial, Medicare or retiree populations. The rating manual allows you to:

• Quickly rate a multitude of benefit plan options
• Estimate the cost of including some form of prescription drug coverage for Medicare-eligible beneficiaries
• Estimate a wide variety of benefit design and pharmacy cost-management programs

The Individual and Small Group Medical Underwriting Guidelines (MUGs) are evidence-based tools for underwriters to assess relative risk based on applicants’ medical and prescription drug histories, helping to determine coverage costs. Key features include:

• Ratings for 1,400+ medical conditions, considering condition-specific factors
• Prescription drug index of 4,000+ medications, with dosage patterns, discounts, and compliance rates
• Drug/condition conversion tables for easy identification
• Debit point distributions for actuarial calculations
• Regular updates for technology, practices, and prescription drugs
• Tailored guidelines for small group underwriting and rating