Insurance Rates vs. Premiums: What’s the Difference?

If you’ve shopped for health insurance or researched plans offered by your employer, you’ve likely come across the terms “rate” and “premium.” At first glance, these two words seem interchangeable. However, rates and premiums refer to distinct aspects of health insurance pricing.

Understanding the difference between insurance rates and premiums enables you to make apples-to-apples comparisons when evaluating plan options. This guide examines rates and premiums in detail, including how they are set, who pays them, and what factors affect the amounts.

What is an Insurance Rate?

An insurance rate refers to the baseline price an insurance company charges for a specific health plan before any adjustments. Rates are based on the average expected costs to the insurer to pay medical claims and administrative fees for a particular policy.

Rates are initially developed using historical claims data and projected future costs. The insurance company then files these proposed rates with state regulatory agencies for review and approval before they can be used.

Some key facts about insurance rates:

• Rates apply to a standard policy and don’t account for individual factors yet.

• Rates must be approved by state regulators before insurers can use them.

• Development of the rates involves complicated actuarial calculations.

• Rates are expressed as a dollar amount, such as $300 per member per month.

• Rates represent the starting point that premiums are later derived from.

Think of rates as the raw price for coverage before any custom adjustments are made for individual plan purchasers. The rate provides the basis for determining premiums.

What is an Insurance Premium?

An insurance premium is the amount a policyholder actually pays for coverage each month. Where rates apply generally to policies, premiums are adjusted to apply to individual purchasers and their profiles.

Factors like age, gender, zip code, family size, and tobacco use mean that no two premiums are alike. Insurers use these rating factors to make appropriate adjustments up or down from the base rate to calculate a customized premium.

Some key facts about insurance premiums:

• Premiums are always tailored to individual circumstances.

• Premiums account for allowable rating factors like age and location.

• Policyholders pay premiums monthly, quarterly, or annually.

• Premiums must be paid to maintain active health plan coverage.

• If premiums lapse, health insurance coverage will be cancelled.

Think of premiums as the customized price each person pays for their particular health policy. While rates provide the starting point, premiums reflect individualized adjustments.

How Are Insurance Rates and Premiums Related?

Insurance rates and premiums are closely connected in the overall pricing process for health plans:

1. Actuarial calculations determine the initial rate

Based on expected medical costs and expenses, actuaries calculate an appropriate rate for policies. This population-wide rate applies generally.

2. Rating factors are used to customize the rate

The insurer adjusts the general rate up or down based on permitted rating factors defined by the state. Common factors include age, gender, location, family size, and tobacco use.

3. The adjusted rate becomes the premium

Applying rating factors yields an individualized premium specific to each policyholder. This customized premium is what enrollees actually pay.

4. Premiums are paid to maintain coverage

Policyholders must pay the insurance premium on time and in full to keep health coverage active. Missed premiums can result in claims denials or termination.

Who Determines Health Insurance Rates?

Setting health insurance rates involves in-depth actuarial analysis. Rates are calculated by professionals known as actuaries using claims experience, medical cost projections, and complex statistical modeling.

Most insurance companies employ actuaries to develop rate recommendations. Larger insurers may have an entire in-house actuarial team. Smaller companies may consult with external actuarial firms.

The actuaries determine an appropriate rate by considering:

• Past claims, including total costs and utilization patterns
• Trends in medical costs and utilization
• New technologies and medications
• Demographic changes in the risk pool
• Administrative expenses
• Target profit margins

Combining these data points enables actuaries to project future costs and arrive at justifiable rate levels. Their proposed rates must also align with state and federal regulations.

How Are Health Insurance Premiums Calculated?

While actuaries determine the base rates, calculating premiums involves adjusting the rates for individual risk profiles. Premiums are derived from the rates using these key steps:

1. Gather rating factor details

Insurers collect information on age, gender, location, family size, tobacco use, and any other approved rating factors.

2. Apply rating factors to the rate

The insurer adjusts the rate up or down corresponding to the rating factors. For example, older individuals may warrant a 50% increase to account for higher expected costs.

3. Add administrative fees

Fees for plan administration and commissions are added on top of the adjusted rate.

4. Calculate subsidies if applicable

For plans sold through ACA marketplaces, subsidies lower premiums for those qualifying based on income.

5. Determine the final premium

After adjustments and subsidies, the final premium for each enrollee is set. This is the monthly amount the policyholder must pay.

By applying this formula uniformly across all enrollees, insurers can derive appropriate premiums tailored to the unique risk profile of each individual or family.

What Factors Influence Insurance Rates and Premiums?

Many variables impact the rates set by insurers as well as the premiums paid by policyholders. Key factors include:

Medical costs – Higher costs to cover doctor visits, hospitalizations, drugs, and procedures drive rates and premiums upward.

Utilization – Frequent use of health services increases claims and expenses, which may increase rates and premiums.

New technologies – New high-cost services and prescription drugs put upward pressure on rates and premiums.

Age – Older individuals are costlier to cover, so age significantly impacts premium adjustments.

Location – Where you live influences rates and premiums because care costs vary regionally.

Plan benefits – Richer plans with lower deductibles and more covered services have higher rates and premiums.

Family size – Covering more people on a policy increases risks and costs, resulting in higher premiums.

Health status – People with chronic illness usually have higher premiums due to higher anticipated costs.

Inflation – As prices throughout the healthcare system rise faster than general inflation, premiums rise too.

Insurers must account for all of these elements when initially setting rates and then calculating premiums for enrollees.

Do Insurance Rates Ever Change?

Insurance rates are reevaluated and refiled on an annual basis. This allows changes in the factors above to be incorporated into updated rates proposed by insurers.

Rate changes must go through a review and approval process with state regulators before taking effect. Insurers must provide actuarial justification and evidence for any proposed rate adjustments.

State regulators aim to ensure any rate changes are reasonable and not excessive. Some common reasons rates may change include:

• Medical cost inflation – Underlying costs of services, drugs, and technology are continually rising. Rate increases account for these added expenses.

• Utilization pattern shifts – If the insured population is using more health services, increased rates help offset the additional costs.

• New benefits mandates – When states require new benefits be covered, rates may rise to maintain adequate funding.

• Risk pool changes – If the insured group is older or sicker, higher rates balance out the greater expected costs.

• Incorrect projections – If claims exceed what was anticipated, rate hikes bring premium revenue in line with actual costs.

While rate changes are subject to regulatory oversight, increases within reason are permitted to keep pace with evolving medical costs over time.

How Much Do Health Insurance Premiums Change Annually?

Premiums rarely stay static year over year. On average, premiums for employer-sponsored health plans rise 5-6% annually. For individual and family plans, average increases are typically 8-10% each year.

However, there is significant variation above and below these averages:

• Premiums may stay flat some years, especially if claims costs are stable and the risk pool is unchanged.
• Large premium spikes can occur following major market shifts or new regulations.
• Employer plan premiums tend to rise slower, as employers absorb some cost increases.
• Premiums for individual plans are increasing faster as enrollees bear the full brunt of rate hikes.
• Age, health status, location and other factors cause divergence in premium changes.

Monitoring key benchmarks like medical cost inflation and per capita health spending provides insights into where premiums may be headed longer-term. While no one can predict exactly how much premiums will