New AIS Report: Individuals Had Significantly Higher Claims Than Groups in 2014

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Members enrolled as individuals cost insurers 12% more than large-group members in 2014, according to a newly released report from Atlantic Information Services.

Members enrolled in health plans as individuals (or families) cost insurers 12% more than large-group members did, and 15% more than small-group members did, in claims filed during 2014, according to Atlantic Information Services, Inc.’s (AIS) Commercial Health Plan Market Metrics: 2014 Performance Measures for Individual, Small-Group and Large-Group Risk-Based Plans. This new report from the editors of AIS’s Directory of Health Plans provides a snapshot of the rapidly evolving commercial risk health insurance market, by assessing the impact of the individual mandate, exchanges and other Affordable Care Act (ACA) initiatives.

To produce Commercial Health Plan Market Metrics, AIS’s in-house researchers analyzed 623 public filings to compare key profitability measures of 195 health insurers offering commercial risk-based products directly to consumers, and to small and large employer groups. Findings illustrate the true impact on the commercial risk-based health insurance market of ACA initiatives, including public exchanges, the individual mandate and essential health benefits.

On average, insurers paid $4,650 per member per year for commercially insured individuals not enrolled via an employer group, AIS researchers found. For small-group members, the average claims expense was $4,034 per member per year, and for large-group members it was $4,142.

Commercial Health Plan Market Metrics offers conclusive, baseline data on covered lives, premium revenue and claims expense for insurers in the post-ACA commercial health plan market. It is intended as a resource for benchmarking comparisons, and for answering the most commonly asked questions about the shifting marketplace, such as:

  • Can insurers make money participating on public exchanges?
  • What are the characteristics of insurers with the best commercial profit margins?
  • Which exchange plans were most successful?
  • Is the CO-OP model unsustainable?

For more information on Commercial Health Plan Market Metrics, including a full table of contents and sample pages, visit

About Atlantic Information Services
Atlantic Information Services, Inc. (AIS) is a publishing and information company that has been serving the health care industry for more than 25 years. It develops highly targeted news, data and strategic information for managers in hospitals, health plans, medical group practices, pharmaceutical companies and other health care organizations. AIS products include print and electronic newsletters, websites, looseleafs, books, strategic reports, databases, webinars and conferences. Learn more at

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Susan Namovicz-Peat, Director, Directories and Databases Division
Atlantic Information Services
+1 (202) 775-9008 Ext: 3045
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Atlantic Information Services, Inc.

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