Compare managed care, preferred provider and high-deductible plan designs against market needs.
Healthcare & Pharmaceutical Management
Health Insurance Product Design and Underwriting Fundamentals
Prepares health insurance product and underwriting professionals to design benefit plans, assess risk and price premiums that remain solvent and competitive.
🗓️Duration5 training days
📚Content4 modules · 8 sessions
🎓On completionAccredited attendance certificate
About the programme
Course Overview
Health insurance products fail commercially when benefit design, underwriting rules and pricing are built in isolation, leaving a plan that attracts the wrong risk mix or breaches solvency and minimum loss ratio requirements within its first renewal cycle. This course starts with benefit design, comparing managed care, preferred provider and high-deductible structures and calculating the actuarial value each design delivers, then moves into provider network strategy and credentialing standards. It covers underwriting principles for individual and group business, the difference between experience and community rating, and how risk pooling and risk adjustment protect a plan against adverse selection. Later modules build actuarial pricing skills, including claims trend analysis, loss ratio testing and reserving for incurred-but-not-reported claims, before addressing regulatory compliance, distribution channels and post-launch performance monitoring. Teaching uses benefit design worksheets, underwriting decision rules and pricing models drawn from individual, group and self-funded health plans. Participants leave able to design, price and govern a health insurance product from concept through to renewal.
Expected Learning Outcomes
Calculate actuarial value to confirm that a benefit design meets its intended coverage level.
Apply underwriting rules appropriate to individual, small-group and large-group business.
Distinguish experience rating from community rating and their effect on group premiums.
Apply risk-adjustment models that redistribute payments between plans with different risk profiles.
Calculate loss ratios and incurred-but-not-reported reserves to test pricing adequacy.
Confirm product compliance with essential benefit, network adequacy and solvency requirements.
Who Should Attend
Health insurance product managers designing new benefit plans.
Underwriters assessing individual and group health insurance risk.
Actuaries pricing premiums and calculating claims reserves.
Provider network managers negotiating health plan contracts.
Compliance officers monitoring solvency and medical loss ratio requirements.
Broker and distribution managers bringing new health plans to market.
Course Modules
Select any module to see its sessions and points.
01Designing the Health Insurance Product
2 sessions · 8 points
Session 1Benefit Design and Plan Types
- Compare managed care, preferred provider and high-deductible plan designs against market needs.
- Structure cost-sharing elements, including deductibles, coinsurance and out-of-pocket maximums.
- Calculate actuarial value to confirm a benefit design meets its intended coverage level.
- Design supplementary benefits, such as telehealth or wellness programmes, within the product.
Session 2Provider Network Design
- Decide between narrow and broad network strategies based on price, access and quality goals.
- Set credentialing and quality standards for providers admitted to the network.
- Negotiate value-based and risk-sharing contract terms with network providers.
- Assess network adequacy against regulatory access and travel-time standards.
02Underwriting Principles and Risk Assessment
2 sessions · 8 points
Session 1Individual and Group Underwriting
- Apply underwriting rules appropriate to individual, small-group and large-group business.
- Distinguish experience rating from community rating and their effect on group premiums.
- Assess group risk factors, including demographic mix, industry and prior claims experience.
- Document underwriting decisions to support regulatory and audit review.
Session 2Risk Pooling and Risk Adjustment
- Explain how risk pooling spreads variable claims cost across a defined population.
- Apply risk-adjustment models that redistribute payments between plans with different risk profiles.
- Structure reinsurance or stop-loss arrangements that protect self-funded plans from large claims.
- Monitor adverse selection indicators that signal a deteriorating risk pool.
03Actuarial Pricing and Reserving
2 sessions · 8 points
Session 1Claims Experience and Trend Analysis
- Analyse historical claims experience by service category to identify emerging cost drivers.
- Apply medical cost trend factors to project future claims for the rating period.
- Calculate loss ratios and use them to test the adequacy of proposed premium rates.
- Segment claims data to distinguish one-off high-cost claims from underlying trend.
Session 2Rate Setting and Reserves
- Build a premium rate proposal that balances competitiveness with actuarial soundness.
- Calculate incurred-but-not-reported reserves to reflect claims liability accurately.
- Prepare rate filings that meet regulatory documentation and justification requirements.
- Test pricing scenarios against minimum loss ratio and solvency requirements.
04Compliance, Distribution and Product Performance
2 sessions · 8 points
Session 1Regulatory Compliance and Plan Documentation
- Confirm product compliance with essential benefit, network adequacy and solvency requirements.
- Prepare plan documents and evidence-of-coverage materials that meet disclosure obligations.
- Monitor medical loss ratio performance and prepare any required rebate calculations.
- Track regulatory changes that require benefit design or filing updates.
Session 2Distribution and Performance Monitoring
- Evaluate broker, exchange and direct-to-consumer distribution channels for a given product.
- Monitor enrolment, persistency and loss ratio performance after product launch.
- Use claims and utilisation data to refine benefit design in the next product cycle.
- Report product performance to executive and actuarial leadership against original pricing assumptions.
What the participant receives
4 course modules
A structured syllabus
8 training sessions
across 5 days
32 detailed points
Applied, detailed content
Accredited attendance certificate
On completing the programme
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