Eligible month or month in which a member has health insurance coverage Incurral date or date of service for all covered professional services
Number of members who had medical health insurance coverage in a given month. A member can either be the subscriber or a dependent. The total of all months that each member was covered is referred to as member months exposed. For example, total medical members were 936,143 in Jan-2014, 936,242 in Feb-2014 and 939,964 in Mar-2014. Therefore, the total member months exposed for the year to date as of March 31, 2014 was 2,812,349.
The maximum amount that a health insurer carrier is willing (usual and customary reasonable) to pay for a specific service, including the patient�s liable amount. For in-network providers (e.g., participating physicians), the allowed amount is a negotiated discounted fee based on the contracts with the providers. The allowed dollar amount incurred in the month is paid through April of the following year and excludes any adjustments for incurred but not reported (IBNR) claims, demographic or industrial.
Number of patient encounters or visits to a provider that have incurred in the month and reported through April of the following year. A visit is a unique combination of a patient and a provider on the same day regardless of the number of services performed by the same provider on the same day.
Observed 12 months ending �Per Member Per Month� cost of all professional services spread across all covered medical members. For example, Jul-2014 PMPM of $113.14 is calculated as 12 months of allow dollars (Aug-2013 � Jul-2014) divided by 12 months of members (Aug-2013 � Jul-2014). In general, PMPM cost is a function of utilization and per unit cost. For example, the PMPM cost can also be calculated as the product of utilization per 1,000 and the average cost per visit divided by 12,000.
Visits per thousand is a standard unit of measurement of utilization. Refers to an annualized use of professional care. It is the number of unique patient visits that have incurred in a year for each thousand covered lives. For example, Jul-2014 visits per 1,000 of 8,376.1 is calculated as 12 months of visits (Aug-2013 � Jul-2014) divided by 12 months of members (Aug-2013 � Jul-2014) multiply by 1,000 members multiply by 12 months.
Observed 12 months ending cost per patient visit for all patients in a 12 month period. For example, Jul-2014 cost per visit of $162.10 is calculated as 12 months of allowed dollars (Aug-2013 � Jul-2014) divided by 12 months of patient visits (Aug-2013 � Jul-2014).
Observed 12 months ending year over year (YOY) change in allowed PMPM cost. For example, the Allowed PMPM Trend as of Jul-2014 of ~1.5% is calculated as Jul-2014 PMPM of $113.14 divided by Jul-2013 PMPM of $111.51 (not shown here) minus 1. Medical claim cost trends are generally considered to be composed of two major components, a trend in price (cost per unit) and a trend in utilization (number of units). For example, the allowed PMPM trend as of a given month (12 months ending) is [(1 + Cost Trend) x (1 + Utilization Trend)] � 1.
Observed 12 months ending year over year (YOY) change in visits per 1,000. For example, the Utilization Trend as of Jul-2014 of ~-1.0% is calculated as Jul-2014 visits per 1,000 of 8,376.1 divided by Jul-2013 visits per 1,000 of 8,460.6 (not shown here) minus 1.
Observed 12 months ending year over year (YOY) change in unit cost per visit. For example, the Cost Trend as of Jul-2014 of ~2.5% is calculated as Jul-2014 unit cost per visit of $162.10 divided by Jul-2013 unit cost per visit of $158.15 (not shown here) minus 1.
Type of coverage in which a member is enrolled for health insurance. The Individual and Small Group markets includes both grandfathered and non-grandfathered members. These markets also includes both off and on Maryland Health Benefit Exchange members. The group size for Small Group is 2 - 50. For Large Group, the group size is 51+ lives. Please note that the Maryland Insurance Administration only rate review the Individual and Small Group markets.
To select a market, do the following:
(i) Unselect the �All� button to clear
(ii) Select a market
(iii) Click on the �apply� button to execute your selection
(iv) To reset, click on the hour glass or the �All� button
EPO means exclusive provider network. An EPO is similar to an HMO in that the member must remain within the pre-determined network to receive benefits. The primary distinction is that an EPO is regulated as an insurance contract or self-funded plan while an HMO may be subjected to different regulatory requirements.
HMO means health maintenance organization. In general, an HMO encompass two possibilities: a licensed health plan (licensed as an HMO) that places at least some providers at risk for medical expenses and a health plan that uses designated (usually primary care) physicians as gatekeepers (some HMOs do not).
POS means point of service. A plan in which members do not have to choose how to receive services until they need them. A member may go out of the provider network to receive benefits. However, the member often receives less coverage for out of network benefits. Some POS plans require designated (usually primary care) physicians as gatekeepers.
PPO means preferred provider organization. A plan that contracts with independent providers as a discount for services. The panel is limited in size and usually has some type of utilization review system associated with it. A PPO may be risk bearing, like an insurance company or may be non-risk bearing like a physician-sponsored PPO that markets itself to insurance companies or self-insured companies by means of an access fee.
Indemnity is generally a health insurance plan that has no restrictions on visits to almost any health provider of your choice. The insurance company then pays a predetermined portion of your total medical charges.
Please note: The Maryland Insurance Administration do not review rates by rating area.
The federal Department of Health and Human Services published final regulations regarding Market Rules and Rate Review on February 27, 2013. A part of these final rules, 45 C.F.R. � 147.102(b)(3), require rating areas for both the individual and small group markets in each State.
Maryland established four geographic rating areas for the small group market in 1993 legislation as (1) the 11Baltimore metropolitan area; (2) the District of Columbia metropolitan area; (3) Western Maryland; and (4) Eastern and Southern Maryland.1 These geographic areas are further defined by county by COMAR 31.11.08 as: 1 Insurance Article, � 15-1205(a)(2)(ii), Annotated Code of Maryland
1. "Baltimore Metropolitan Area" means Baltimore City, Baltimore County, Harford County, Howard County, and Anne Arundel County.
2. "Eastern and Southern Maryland" means St. Mary's County, Charles County, Calvert County, Cecil County, Kent County, Queen Anne's County, Talbot County, Caroline County, Dorchester County, Wicomico County, Somerset County, and Worcester County.
3. "Washington, D.C. Metropolitan area" means Montgomery County and Prince George's County.
4. "Western Maryland" means Garrett County, Allegany County, Washington County, Carroll County, and Frederick County.
� Insurance Article, � 15-1205(a)(2)(ii), Annotated Code of Maryland
Source: http://insurance.maryland.gov/Insurer/Documents/bulletins/bulletin-13-08-geographicratingareas.pdf
Please note: The Maryland Insurance Administration do not review rates by age range. Age is based on age on last birthday.
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