What is ADVERSE SELECTION in Health Insurance?


By staff reporters

The tendency of people who are less than standard health insurance risks to seek or continue insurance to a greater extent than other individuals.  This so called “selection against the insurer”, or “anti-selection”, is a form of stacking the deck and is also found in the tendency of policy owners to take advantage of favorable options in health insurance or managed care contracts.

Or, a particular health plan, whether indemnity or managed care, is selected against by the enrollee, and thus an inequitable proportion of enrollees requiring more medical services are found in that plan.

Example:   Low enrollee out-of-pocket costs might lure those individuals requiring more health services into an HMO rather than an indemnity-plan because the former does not have a deductible.

Therefore, the HMO would have a greater proportion of less-healthy enrollees, thereby driving up costs and increasing financial risks. Also occurs with one of the following:

  1. When a premium doesn’t cover costs. Some populations, perhaps due to age or health status, have a great potential for high utilization.
  2. Some population parameter such as age (e.g., a much greater number of 65-year-olds or older to young population) that increases the potential for higher utilization and often increases costs above those covered by a payer’s capitation rate.



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