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ASES says actuaries set Plan Vital premiums; negotiations continue as insurers raise concerns
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Summary
Agency officials told a public hearing that actuarial rebasing and annual certification determine Plan Vital premiums and that insurers have raised concerns but no formal withdrawals were reported; actuaries certified an amendment June 14, 2024 and the year-3 process began in August.
Unidentified Speaker 1 pressed ASES officials on how Plan Vital premiums are set and whether insurers can refuse the rates.
Agency representative (Unidentified Speaker 2) said the state sets actuarially certified premiums under federal rules and the contract: “el estado establece las primas, ... un actuario licenciado es el que está asumiendo el riesgo y la responsabilidad …” The official said actuaries completed a certification for the year‑2 amendment on June 14, 2024 and issued further actuarial versions in August and September as part of the year‑3 negotiation.
Why it matters: the certified premium determines the monthly capitation paid into insurer contracts and flows through payments to provider groups (IPAs). If a premium is set too low relative to actual claims, insurers may report financial pressure or consider contract exit; if set too high it affects government budgets.
ASES described the process: the agency—s actuaries perform a baseline "rebasing" annually to analyze costs and recommend a certified premium for submission to the federal government. Unidentified Speaker 2 said actuaries "emitieron tres versiones diferentes" and the most recent was shared with insurers in September and communicated in October.
Insurer responses and legal framework: ASES told the hearing that insurers may voice concerns and, contractually, may reserve rights to exit a market, but the process gives the state authority to set the certified premium. "Hay aseguradoras que han notificado que no están conformes... ninguna ha hecho una afirmación formal por escrito que ha decidido salir del plan, a mi mejor conocimiento," Unidentified Speaker 2 said.
What remains unresolved: Negotiations for the contract year that began Oct. 1, 2024 were ongoing at the time of the hearing. ASES said that, while insurers can raise objections, the state—s actuarially certified premium is the controlling figure absent further federal action. The hearing did not record any formal vote or decision; ASES and actuaries will continue the certification and negotiation process.
The hearing paused briefly to seek a sensitive consolidated number off the public record; officials resumed public proceedings afterward.
