Health Cost Guidelines - Commercial

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The Health Cost Guidelines—Commercial include three volumes and two rating models:

Commercial Rating Structures

Determine utilization, charge levels, and claim costs for health benefits provided by traditional fee-for-service plans, alternative delivery systems (such as HMOs, PPOs or systems using modified fee-for-service reimbursement methods), and freestanding or integrated prescription drug programs.

Commercial Area Factors

Adjust national average costs to specific geographic areas. Used in conjunction with the Commercial Rating Structures.

Claim Probability Distributions

Assess the value of deductibles, out-of-pocket maximums, and the effect of plan maximums. Claim probability distributions can also be used to develop high-deductible claim costs for reinsurance, individual stop-loss and pooling charges, risk charges, contingency margins, credibility and selection factors, and aggregate stop-loss structures.

Managed Care Rating Model

This Excel rating tool automates the input and calculation of many rating variables and worksheets described in other sections of the rating structures, including the provider reimbursement worksheets and claim probability distributions.

Prescription Drug Rating Model

This rating model incorporates the prescription drug rating section, providing rating variables for a more detailed analysis of prescription drug costs and benefits. The model includes cost per prescription continuance tables used to model unit price variation and effectiveness (expected versus nominal).

Up-to-date and specific to your needs

The Health Cost Guidelines—Commercial are kept current with annually updated benefit descriptions in the Health Cost Guidelines categorization, and medical trend assumptions and considerations.

The Commercial Guidelines feature:

  • Major Medical Rating Structure
  • Managed Care Rating Structure
  • Prescription Drug Rating Structure
  • Basic Tables
  • Trend Factors
  • Area Factors
  • Claim Probability Distributions
  • Cost Management
  • Mandated Benefits
  • Rating Examples
  • Managed Care Rating Model
  • RX Rating
  • Benefit Descriptions
  • Demographics
  • DRG (Admit, LOS) Models
  • Supplemental Sections: Cost Management, Mandated Benefits, Individual and Small Group Rating Considerations, Experience Rating
  • Mandated Benefits
  • Individual and Small Group Rating Considerations
  • Experience Rating

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The products we sell are the tools we use

As the premier health management consulting firm, the Health Cost Guidelines are used daily by our own in-house actuarial consultants for insight into the key drivers of healthcare costs and utilization.

The Health Cost Guidelines Suite includes the following products:

Contact your Milliman consultant or the Health Cost Guidelines Manager at if you are interested in licensing any of these products.

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