Can a large group renewal use the group's claims experience?

The aggregate rate for the group can reflect its experience, subject to state law. No individual in the group may be charged more for a health factor, and genetic information may not be used, so the software prices at group level only.

How is this different from risk adjustment?

Risk adjustment looks at members who are already enrolled and documents their conditions for payment. This work prices a risk before cover is written. We build both, on separate pages and separate data paths.

Can stop-loss quotes be fully automated?

We do not recommend it. Software can validate the census, summarise claims, flag large claims and draft specific and aggregate options. An underwriter reviews the evidence and signs off the quote.

How do you protect census and claims data?

With HIPAA-ready engineering: access by role, encryption in transit and at rest, audit logs and de-identified test data. Agnotic signs a business associate agreement before working with protected health information.

What drives the cost of automating health insurance risk assessment?

The markets and states in scope, the number of census and claims formats, the actuarial models to connect, the broker portal and the audit requirements. We go through these drivers on the scoping call and agree a fixed first release.

A care team reviewing patient risk charts on a large wall screen in a hospital meeting room

Insurtech / Health Insurance Risk Assessment

Automating health insurance risk assessment

A pricing engine that is legal for a large group renewal can break the law in the individual market. Agnotic Technologies builds health underwriting tools that apply only the factors each market allows, prepare the evidence and leave every quote decision to an underwriter.

15-Minute Scoping Call

By market

Permitted factors only

Census

Validated before rating

Sign-off

Underwriter on every quote

Trusted by global innovators

Industry Overview

What does automating health insurance risk assessment involve?

Automating health insurance risk assessment means using software to price a group or individual risk before cover is written, with only the factors each market allows. Agnotic Technologies builds these tools for health carriers, MGAs and stop-loss writers: census intake, claims experience analysis, stop-loss quoting and rating factor checks, with an underwriter signing off each quote.

Industry Challenges

Why is health underwriting automation risky?

The risk is rarely the maths. It is using the right maths in the wrong market, or losing track of why a price came out as it did.

One rating engine serves several markets, and a health factor that is allowed in one leaks into another.
Group census files arrive in many layouts with missing dates of birth, wrong tiers and duplicates.
Prior carrier claims experience is incomplete, and nobody records which months or claims were missing.
Stop-loss quotes are built in spreadsheets that cannot be reproduced when a broker asks why.
Underwriters override results without a reason on file, so the next renewal starts from guesswork.
Models and rate tables change without a record of which quotes used which version.

Our Approach

How should a carrier approach underwriting automation?

Three rules keep automation useful and inside the law.

Start from the market

The market segment and state are chosen first, and they decide which factors the engine may even see.

Keep a person on the decision

Software prepares the data, the analysis and a draft quote. An underwriter approves, changes or declines it, with a reason.

Make every quote reproducible

Inputs, rate table versions, model versions and overrides are stored, so any quote can be rebuilt exactly.

Capabilities

What do we build for health underwriting teams?

Tools for pricing risk before cover is written. Risk adjustment on members already enrolled is a different job, covered on our payer analytics page.

Census intake and validation

Broker census files in any layout mapped to one format, with errors and gaps listed before rating.

Claims experience analysis

Prior carrier or TPA claims summarised by period, with trend, large claims and missing data shown to the underwriter.

Stop-loss quote builder

Specific and aggregate options for self-funded employers, built from census and claims data for underwriter review.

Rating factor rules by market

Permitted factors set per market and state, with blocked factors tested so they cannot reach the price.

Underwriter workbench

Draft quotes, evidence, referrals and overrides in one view, with a reason required for every change.

Quote audit trail

Inputs, versions and decisions stored with each quote, ready for an internal or regulatory review.

Broker submission portal

Brokers upload census and claims files and track each quote's status.

Hand-off to enrolment

Sold cases passed to policy and enrolment systems with the agreed rates.

Engineering Stack

Systems and standards behind health underwriting tools

Chosen to fit your brokers, your actuarial models and your policy administration system.

Data intake

Census spreadsheets and CSVX12 834 enrollment filesClaims experience extractsLarge claim reports

Rating

Rules engine with market and state factor setsVersioned rate tablesActuarial model interfaceQuote document generation

Data

PostgreSQLData warehouseDe-identified test data setsModel version registry

HIPAA-ready engineering

Role-based access to census and claims dataAudit loggingEncryption in transit and at restBAA-covered cloud hosting

Decision table

Which risk factors may each health market use?

This table is the first thing we agree with your compliance team. State law can narrow it further, so each state's rules are added on top.

Health insurance market segments with the risk factors permitted, the rule that sets them and what software may automate
Market segment	Factors permitted in pricing	Rule that sets them	What software may automate
ACA individual market	Individual or family, rating area, age (up to 3:1 for adults) and tobacco use (up to 1.5:1)	45 CFR 147.102, with guaranteed availability under 45 CFR 147.104	The rate calculation from the permitted factors, and a check that no other factor is applied
ACA small group	The same four factors, applied per enrollee, with the rating area set by the employer's principal business address	45 CFR 147.102	Census validation, age and tobacco factors and rating area lookup; no group health experience in the rate
Large group, insured	The group's aggregate claims experience may affect its rate; individuals may not be charged more for a health factor, and genetic information may not be used	45 CFR 146.121(c)(2) and 146.122(b), plus state rating law	Experience analysis, trend and credibility prepared for an underwriter; list billing by health factor blocked
Self-funded with stop-loss	The stop-loss writer prices the employer's plan risk for specific and aggregate cover	State stop-loss insurance law; the plan keeps its own duties to participants	Census and claims intake, large claim review and a draft quote for underwriter sign-off
Supplemental cover	Depends on the product and the state, under the filed underwriting guidelines	State insurance law and the filed product	Application intake and checks against the filed guidelines

Measured Impact

What should an underwriting team track?

Measures we build into the underwriting dashboard.

Turnaround

Submission to quote

Time from a complete broker submission to a signed-off quote.

Exceptions

Data issues

Census and claims problems found at intake, by broker.

Overrides

Underwriter changes

Quotes changed after the draft, with the reasons given.

Bound

Quoted vs sold

Quotes that became policies, by market and broker.

Use Cases

Where do health underwriting builds start?

Common first releases, each scoped to one market segment.

Stop-loss quoting desk

Census, claims and draft quotes for self-funded employers in one workbench.

Small group quoting

Permitted factors applied consistently, with census errors caught first.

Large group renewals

Experience analysis prepared for underwriters before each renewal.

Broker census portal

One place for brokers to submit files and follow quotes.

Rating rule testing

Automated tests that prove blocked factors never reach the price.

Stop-loss MGA launch

A first quoting system for a new stop-loss program.

Integrations

Which systems do health underwriting tools connect to?

The parties and systems that supply data to a quote or receive it.

Submissions

Brokers and quoting portals

Claims experience

Prior carriers and TPAs

Pricing

Actuarial models

Sold cases

Policy administration

Membership

Enrolment systems

Risk transfer

Reinsurers

Quote letters

Document generation

Reporting

Data warehouse

What we check

Which automated steps need an underwriter's sign-off?

The controls an automated underwriting process needs. Gaps here are where automation creates legal or pricing risk.

Data intake

Census validated with an exceptions list
Claims experience source and months recorded
Access to census and claims data limited by role

Rating

Factor set chosen by market and state before rating
Blocked factors covered by automated tests
Rate table and model versions stored with each quote

Quote decision

An underwriter approves every quote
Every override needs a written reason
Any quote can be rebuilt from stored inputs

Monitoring

Rule and model changes reviewed before release
Test cases run for each market on every change
Audit log reviewed on a set schedule

Compliance-First Development Services Backed by Global Standards

We build secure, scalable products designed for privacy, interoperability, and regulatory readiness from day one across every sector we serve.

Health Insurance Portability and Accountability Act

Protect PHI with privacy-first architecture, encrypted storage and transmission, and strict access controls.

Service Organization Control 2

Verified controls for security, availability, and confidentiality of enterprise data systems.

Information Security Management

Adhering to the international gold standard for managing information security risks.

Our Edge

Why Global Leaders Choose Us

We combine deep technical expertise with industry-specific knowledge to deliver solutions that aren't just functional, but transformational.

Enterprise-Grade Security

We implement rigorous security protocols and compliance standards (HIPAA, GDPR, SOC2) across all industrial solutions to protect sensitive data.

High-Performance Scaling

Our architectures are built to handle massive data loads and user bases, keeping performance steady whether you're serving ten or ten million.

Accelerated Time-to-Market

Using our suite of internal tools and proven frameworks, we cut setup work so your first release reaches users sooner.

Embedded AI Integration

Beyond simple wrappers, we build deep-learning integrations and predictive analytics directly into the core of your industry-specific workflows.

Engagement Model

How does an underwriting automation engagement work?

We start with one market segment and the rules that govern it. Timing depends on scope; we agree a fixed first release on the scoping call.

Scoping call

Markets, states, brokers and data sources, and the quoting step that takes longest today.

Rule mapping with compliance

Permitted and blocked factors per market and state agreed and written as testable rules.

Fixed-scope first release

One market, such as stop-loss or small group, from submission to signed-off quote.

Add markets and checks

More segments and states on the same rules engine and audit trail.

Support

Rate table, rule and model updates released under agreed change control.

Facts and sources

Which federal rules limit health risk pricing?

Short facts we design around, each linked to its primary source on the eCFR.

In the individual and small group markets, a premium rate may vary only by individual or family coverage, rating area, age (no more than 3:1 for adults aged 21 and over) and tobacco use (no more than 1.5:1).
Source: 45 CFR 147.102(a) (eCFR)
A health insurance issuer in the individual, small group or large group market must offer all products approved for sale in that market to any individual or employer in the state, and must accept any that applies.
Source: 45 CFR 147.104(a) (eCFR)
Federal nondiscrimination rules do not restrict the aggregate amount an employer may be charged for group coverage, but an issuer may not quote or charge a different premium for an individual within a group of similarly situated individuals based on a health factor such as claims experience or medical history.
Source: 45 CFR 146.121(a) and (c)(2) (eCFR)
A group health plan, or an issuer offering coverage in connection with one, must not adjust premium or contribution amounts for the plan or any group of similarly situated individuals on the basis of genetic information.
Source: 45 CFR 146.122(b)(1) (eCFR)

Voice of success

We don't just build products; we forge lasting partnerships. See how we've helped industry leaders transform their vision into technical reality.

“I can clearly see how Agnotic has a unique way of handling end-to-end development. They are always active on quick chat and provide support quickly.”

Aaron Phelan

Founder, Benchmark

“Agnotic combines deep technical expertise with strong domain knowledge. They understand the business context, anticipate challenges, and make collaboration smooth and effective.”

John Pasmore

Founder, Latimer

“Agnotic is the best technical team we evaluated. Their engineering excellence made our work dramatically easier and allowed us to stay focused on what matters most for maternal care outcomes. They took full ownership of the technical execution, and we are always happy to continue working together.”

Kim Smith

Founder, My Lauren

Related payer and insurance services

This page covers pricing risk before cover is written. These pages cover what happens after members enrol.

The Same Engineering Patterns, Across Other Industries

The technical patterns behind this platform translate naturally into adjacent verticals.

Healthcare

Payer, claims and member software built with HIPAA-ready engineering.

Financial Services

Quoting, billing and reconciliation patterns shared with financial products.

AI

Models that prepare evidence for an underwriter instead of deciding alone.

Frequently Asked Questions

No. In those markets the rate may vary only by individual or family coverage, rating area, age and tobacco use. The engine blocks every other factor for those segments, and automated tests prove it.