Scoring & Metrics for Fully Insured Groups Defining Scoring & Metrics
CaptureLifestyle Risk Score
The CaptureLifestyle risk score assigns a relative risk score to the group based on lifestyle, behavioral, and social factors ( Diet, Physical Activity, BMI, Alcohol, and Smoking).
This CaptureLifestyle risk score can be used in conjunction with the CaptureHealth risk score to develop a group's final premium.
Underwriting and Pricing applications for the CaptureLifestyle risk score include:
- Small groups where a CaptureHealth risk score is not available
- Groups with low match (hit) rates via the CaptureHealth risk score
- Large groups where a CaptureHealth risk score is not run
- An underwriting judgment factor to apply when setting or revising rates
- The basis is establishing programs that incentivize behavior change to improve members' health status and potentially prevent or lower the severity of future high-cost medical events.
The CaptureLifestyle risk score is calculated to include and exclude a demographic factor to align with the CaptureHealth risk score that is used.
The CaptureLifestyle risk score is based on:
- 5,000+ behavioral & consumer attributes
- 2,000+ social determinants of health factors
- 250+ high-cost condition propensity models
CaptureHealth Risk Score
The CaptureHealth risk score assigns a relative risk score to the group based on health status (morbidity) that is determined from diagnosis (medical claims) and prescriptions (drug claims).
The CaptureHeath risk score of 1.0 represents the average baseline score for a group with average expected healthcare costs.
- Groups with risk scores less than 1.0 are considered lower risk and are projected to have lower healthcare costs.
For example,
A group with a risk score of 0.50 is expected to be 50% of the cost of a group with average healthcare costs (with a risk score = 1.0).
- Groups with risk scores exceeding 1.0 are considered to be at higher risk and are projected to have higher healthcare costs.
For example,
A group with a risk score of 1.30 is expected to have 30% higher healthcare costs than a group with average costs (with a risk score = 1.0).
This CaptureHealth risk score is used, along with the other rating factors in the rating model (demographic, area), to develop a group's premium.
The CaptureHealth risk score is calculated to include or exclude a demographic factor. If the rating model includes (excludes) a demographic factor, the risk score without (with) the demographic factor is used in the rating model.
The premium developed is before any underwriting adjustments and retention items (additional taxes, fees, TPA expenses, and broker commissions).
The CaptureHealth risk score is based on:
- 74,000+ ICD-10 codes
- 110,000 Rx NDC codes
Capture360 Loss Ratio
Verikai loss ratio prediction factor.
This score is used to adjust premiums set using your manual’s age/gender/zip factors.
Predicts loss ratio; represents: a) Verikai predicted claims, divided by b) assumed premiums from your manual. Use this score to adjust premiums to reach an expected target loss ratio.
CaptureHealth Loss Ratio is the predicted loss ratio of the individual or group prior to subjective underwriting discounts and retention (additional variables you would add on, such as additional taxes, fees, TPA, marketing broker fees, etc.).
- Relative to 1.0 and incremental to your existing demographic factors
- Manual+ = 1.0 represents the average for that specific age/gender/zip
- Manual+ < 1.0 --> actual risk is less than reflected by demographic factors
- Manual+ > 1.0 --> actual risk is greater than reflected by demographic factors
This score utilizes:
- 5,000+ behavioral & consumer attributes
-
2,000+ social determinants of health factors
-
250+ high-cost condition propensity models
- 74,000+ high-cost condition ICD-10 codes
-
110,000+ high-cost Rx NDC codes
-
Detailed price & remittance data
-
Specific medical data for dependents under 18
Capture360 Claims +
Verikai adjusted Age, Gender, and Geography manual factor.
Total risk score, including Demographic and Morbidity
Adjusts manual base rate; represents ALL risk adjustments relative to the manual base rate
- Relative to 1.0 and includes demographic factors
- Claims+ = 1.0 represents the national average across all ages & genders
- Claims+ < 1.0 --> actual expected claims less than national average
- Claims+ > 1.0 --> actual expected claims greater than national average
This score utilizes:
- 5,000+ behavioral & consumer attributes
-
2,000+ social determinants of health factors
-
250+ high-cost condition propensity models
- 74,000+ high-cost condition ICD-10 codes
-
110,000+ high-cost Rx NDC codes
-
Detailed price & remittance data
-
Specific medical data for dependents under 18
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