Your bad year wasn't what the carrier said it was.
Enter what your carrier told you. Enter what you actually know. Watch what they didn't show you.
Your Numbers
Three things you already know
The math does the rest.
Employees on Plan100
Cost Per Employee / Year$10,000
★ $9,500–$10,000 is typical for most mid-market employers.
Your MLR came in at…110%
The loss ratio your carrier reported to justify the renewal.
Members driving the cost2
How many people drove most of the claims this year.
Avg cost per claimant$175K
What each of those high-cost claims roughly ran.
Carrier's Pooling Point$75K
The per-claimant cap. Anything above this is covered by the carrier's own reinsurance — not your premium.
01
Carrier says your total claims were
$1,100,000
110% MLR
This is the number they'll use to justify your renewal. Watch what happens when we pull it apart.
02
But on those 2 high claims…
Total Billed
$350,000
Carrier Paid
$150,000
Reinsurance Covered
$200,000
The carrier's exposure was capped at $75K per claimant. Their own reinsurance absorbed the rest — 57% of those claims.
03
Carrier's actual cost — after the offsets
Reported claims$1,100,000
− Reinsurance offset−$200,000
− Rx rebates kept by carrier (6%)−$60,000
Carrier's Real Cost$840,000
That's the number they never put on your renewal. Translate it back to MLR and you get the real picture.
The two MLRs · Theirs vs. the real one
Your Renewal Is Based On
110%
The reported MLR
vs.
The Carrier's Actual MLR
84%
After reinsurance + rebates
Without your high claimants, your group was a healthy book of business. With them, the carrier's own reinsurance absorbed the difference. That's not a bad year — that's a healthy group with a few big claims, billed back to you as a disaster.
The Next Question
Your "bad year" was a healthy group with a few big claims — billed back to you as a disaster. What would it look like if you owned the data?
In a self-funded or captive structure, stop-loss handles the big claims directly — and you see every dollar. No black box. No inflated MLR. No surprise renewal.
For illustration only · Pattern estimates from industry-standard ranges