[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"skill:01M6XF6MX7PZTP14SC1P664MTZ":3,"skill-same:01M6XF6MX7PZTP14SC1P664MTZ":78},{"skillNo":4,"name":5,"nameZh":6,"description":7,"descriptionZh":6,"repositoryFullName":8,"ownerLogin":9,"ownerAvatarUrl":10,"ownerAccountNo":11,"ownerDisplayName":12,"repositoryNo":13,"starsCount":14,"licenseSpdxId":15,"licenseFileUrl":6,"sourceHtmlUrl":16,"categories":17,"keywords":18,"publishedAt":40,"linkOnly":41,"markdownContent":42,"markdownBody":43,"frontMatter":44,"refName":56,"commitSha":57,"skillDirectory":58,"forksCount":59,"repositoryHtmlUrl":60,"repositoryHomepageUrl":6,"ownerHtmlUrl":61,"ownerBlogUrl":6,"ownerDescription":62,"updatedAt":63,"install":64,"resources":77},"01M6XF6MX7PZTP14SC1P664MTZ","analyzing-health-insurance-plans",null,"Evaluates health insurance plan structures with actuarial value, network analysis, and cost projection. Use when analyzing health plans, comparing coverage, or projecting healthcare costs.","FDU-INS\u002FInsurance-Skills","FDU-INS","https:\u002F\u002Favatars.githubusercontent.com\u002Fu\u002F167067594?v=4","01M6XEYMRS4CVJMZ834YWE66BV","FDU-Insurance","01M6XEYMXPDA34HFM0ZE6AY78G",82,"Apache-2.0","https:\u002F\u002Fgithub.com\u002FFDU-INS\u002FInsurance-Skills\u002Fblob\u002Fmain\u002FSkills\u002Fanalyzing-health-insurance-plans\u002FSKILL.md",[],[19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39],"analyzing","analyzing health insurance plans","insurance","health","health insurance","plans","use","actuarial","when","value","with","network analysis","en","cost","coverage","plan","healthcare","science","analysis","network","report","2026-11-10 10:12:30",false,"---\nname: analyzing-health-insurance-plans\nlanguage: en\ndescription: Evaluates health insurance plan structures with actuarial value, network analysis, and cost projection. Use when analyzing health plans, comparing coverage, or projecting healthcare costs.\ntags:\n  - analysis\n  - insurance\nmetadata:\n  author: casemark\n  practice_areas:\n    - Insurance\n    - Actuarial Science\n    - Reinsurance\n  document_types:\n    - Analysis Report\n  skill_modes:\n    - Analysis\n---\n# Analyzing Health Insurance Plans\n\n## When To Use\n\n- Comparing multiple health insurance plan options (employer group, individual market, or Medicare Advantage)\n- Evaluating actuarial value and metal-tier classification accuracy\n- Projecting out-of-pocket costs under different utilization scenarios\n- Assessing network adequacy for a specific population or geographic area\n- Reviewing plan design changes for renewal or repricing cycles\n- Analyzing reinsurance attachment points and stop-loss adequacy relative to plan exposure\n\n## Inputs To Gather\n\n- **Plan documents**: Summary of Benefits and Coverage (SBC), Schedule of Benefits, Certificate of Coverage, Evidence of Coverage\n- **Rate filings**: Premium rates by tier (single, employee+spouse, family), age-banding tables if applicable\n- **Network data**: Provider directory or network ID, in-network vs. out-of-network reimbursement schedules, any tiered or narrow network designations\n- **Claims history** (if available): Aggregate paid claims, large-claimant data, utilization rates by service category\n- **Census data**: Member demographics, enrollment counts by tier, geographic distribution\n- **Formulary**: Drug tier structure, prior authorization requirements, specialty drug handling\n- **Reinsurance\u002Fstop-loss terms**: Specific and aggregate attachment points, lasering exclusions, contract period (paid vs. incurred basis)\n- **Comparison context**: Benchmark plans, prior-year plan design, or competing carrier quotes\n\n## Workflow\n\n1. **Classify the plan structure**\n   - Identify plan type: HMO, PPO, EPO, POS, HDHP\u002FHSA-eligible, or hybrid\n   - Confirm metal tier (Bronze\u002FSilver\u002FGold\u002FPlatinum) or equivalent actuarial value band\n   - Note any non-standard design features: reference-based pricing, direct primary care carve-outs, or centers-of-excellence requirements\n\n2. **Calculate actuarial value**\n   - Map cost-sharing parameters: deductible, coinsurance, copays, out-of-pocket maximum (OOPM)\n   - Apply standard continuance tables or the CMS AV Calculator methodology to estimate the plan's share of total allowed costs [VERIFY: confirm which AV calculator version or methodology is required for the filing year]\n   - Flag deviations from de minimis AV ranges for the stated metal tier (±2 percentage points under ACA rules) [VERIFY: state-specific AV requirements may differ]\n\n3. **Analyze network adequacy**\n   - Check provider-to-member ratios for primary care, specialty, and facility categories against applicable state or CMS standards [VERIFY: network adequacy standards vary by state and market segment]\n   - Identify geographic access gaps using drive-time\u002Fdistance thresholds\n   - Assess out-of-network exposure: balance billing protections, surprise billing act applicability, reference pricing methodology\n\n4. **Project member cost exposure**\n   - Model total cost of care under low, moderate, and high utilization scenarios\n   - Calculate effective member cost share: premiums + expected out-of-pocket spend per scenario\n   - Compare across plans using equivalent annual cost metrics (premium + expected OOP at each utilization level)\n   - For HDHP plans, factor in HSA\u002FHRA employer contributions and tax-advantage value\n\n5. **Evaluate pharmacy benefits**\n   - Map formulary tiers and typical member cost for high-utilization drug categories\n   - Identify specialty drug exposure and accumulator\u002Fmaximizer program impact on OOPM\n   - Note step therapy, prior authorization, and quantity limit protocols\n\n6. **Assess risk transfer and reinsurance**\n   - Review specific stop-loss attachment points relative to historical large-claimant frequency\n   - Evaluate aggregate stop-loss corridor and expected claims variability\n   - Flag any lasered members or excluded conditions and quantify retained risk\n   - For self-funded plans, assess claims-fund adequacy and IBNR reserves\n\n7. **Compile comparative analysis**\n   - Build side-by-side comparison matrix covering: premiums, cost sharing, AV, network breadth, pharmacy, and risk transfer\n   - Rank plans on total effective cost, network quality, and financial risk exposure\n   - Highlight material trade-offs (e.g., lower premium but narrow network, high deductible offset by HSA funding)\n\n## Output\n\n- **Plan Analysis Summary**: One-page overview with plan classification, AV calculation result, and key cost metrics\n- **Cost Projection Table**: Low\u002Fmoderate\u002Fhigh utilization scenario modeling with annual premium + OOP totals per plan\n- **Network Adequacy Assessment**: Provider ratio analysis, geographic access findings, and out-of-network risk notes\n- **Pharmacy Benefit Summary**: Formulary tier structure, specialty drug exposure, and accumulator program flags\n- **Reinsurance\u002FStop-Loss Review** (if applicable): Attachment point adequacy, retained risk quantification, and lasering impact\n- **Comparative Matrix**: Side-by-side plan ranking with trade-off commentary\n- **Flagged Items**: Any data gaps, assumptions made, or items requiring [VERIFY] follow-up\n\n## Quality Checks\n\n- Confirm all cost-sharing parameters (deductible, coinsurance, copay, OOPM) are captured for both in-network and out-of-network tiers\n- Verify AV calculations use the correct methodology and plan year assumptions\n- Ensure utilization scenarios reflect realistic claims distributions (not just arbitrary multiples)\n- Check that premium comparisons use consistent contribution assumptions (gross vs. net of employer subsidy)\n- Validate network data is current — provider directories can be 60–90 days stale\n- Confirm reinsurance terms match the contract period and claims basis (paid vs. incurred)\n- Flag any state-mandated benefit requirements that could affect plan design comparability [VERIFY: essential health benefit benchmark varies by state]\n- Mark all jurisdiction-dependent regulatory references with [VERIFY]\n","# Analyzing Health Insurance Plans\n\n## When To Use\n\n- Comparing multiple health insurance plan options (employer group, individual market, or Medicare Advantage)\n- Evaluating actuarial value and metal-tier classification accuracy\n- Projecting out-of-pocket costs under different utilization scenarios\n- Assessing network adequacy for a specific population or geographic area\n- Reviewing plan design changes for renewal or repricing cycles\n- Analyzing reinsurance attachment points and stop-loss adequacy relative to plan exposure\n\n## Inputs To Gather\n\n- **Plan documents**: Summary of Benefits and Coverage (SBC), Schedule of Benefits, Certificate of Coverage, Evidence of Coverage\n- **Rate filings**: Premium rates by tier (single, employee+spouse, family), age-banding tables if applicable\n- **Network data**: Provider directory or network ID, in-network vs. out-of-network reimbursement schedules, any tiered or narrow network designations\n- **Claims history** (if available): Aggregate paid claims, large-claimant data, utilization rates by service category\n- **Census data**: Member demographics, enrollment counts by tier, geographic distribution\n- **Formulary**: Drug tier structure, prior authorization requirements, specialty drug handling\n- **Reinsurance\u002Fstop-loss terms**: Specific and aggregate attachment points, lasering exclusions, contract period (paid vs. incurred basis)\n- **Comparison context**: Benchmark plans, prior-year plan design, or competing carrier quotes\n\n## Workflow\n\n1. **Classify the plan structure**\n   - Identify plan type: HMO, PPO, EPO, POS, HDHP\u002FHSA-eligible, or hybrid\n   - Confirm metal tier (Bronze\u002FSilver\u002FGold\u002FPlatinum) or equivalent actuarial value band\n   - Note any non-standard design features: reference-based pricing, direct primary care carve-outs, or centers-of-excellence requirements\n\n2. **Calculate actuarial value**\n   - Map cost-sharing parameters: deductible, coinsurance, copays, out-of-pocket maximum (OOPM)\n   - Apply standard continuance tables or the CMS AV Calculator methodology to estimate the plan's share of total allowed costs [VERIFY: confirm which AV calculator version or methodology is required for the filing year]\n   - Flag deviations from de minimis AV ranges for the stated metal tier (±2 percentage points under ACA rules) [VERIFY: state-specific AV requirements may differ]\n\n3. **Analyze network adequacy**\n   - Check provider-to-member ratios for primary care, specialty, and facility categories against applicable state or CMS standards [VERIFY: network adequacy standards vary by state and market segment]\n   - Identify geographic access gaps using drive-time\u002Fdistance thresholds\n   - Assess out-of-network exposure: balance billing protections, surprise billing act applicability, reference pricing methodology\n\n4. **Project member cost exposure**\n   - Model total cost of care under low, moderate, and high utilization scenarios\n   - Calculate effective member cost share: premiums + expected out-of-pocket spend per scenario\n   - Compare across plans using equivalent annual cost metrics (premium + expected OOP at each utilization level)\n   - For HDHP plans, factor in HSA\u002FHRA employer contributions and tax-advantage value\n\n5. **Evaluate pharmacy benefits**\n   - Map formulary tiers and typical member cost for high-utilization drug categories\n   - Identify specialty drug exposure and accumulator\u002Fmaximizer program impact on OOPM\n   - Note step therapy, prior authorization, and quantity limit protocols\n\n6. **Assess risk transfer and reinsurance**\n   - Review specific stop-loss attachment points relative to historical large-claimant frequency\n   - Evaluate aggregate stop-loss corridor and expected claims variability\n   - Flag any lasered members or excluded conditions and quantify retained risk\n   - For self-funded plans, assess claims-fund adequacy and IBNR reserves\n\n7. **Compile comparative analysis**\n   - Build side-by-side comparison matrix covering: premiums, cost sharing, AV, network breadth, pharmacy, and risk transfer\n   - Rank plans on total effective cost, network quality, and financial risk exposure\n   - Highlight material trade-offs (e.g., lower premium but narrow network, high deductible offset by HSA funding)\n\n## Output\n\n- **Plan Analysis Summary**: One-page overview with plan classification, AV calculation result, and key cost metrics\n- **Cost Projection Table**: Low\u002Fmoderate\u002Fhigh utilization scenario modeling with annual premium + OOP totals per plan\n- **Network Adequacy Assessment**: Provider ratio analysis, geographic access findings, and out-of-network risk notes\n- **Pharmacy Benefit Summary**: Formulary tier structure, specialty drug exposure, and accumulator program flags\n- **Reinsurance\u002FStop-Loss Review** (if applicable): Attachment point adequacy, retained risk quantification, and lasering impact\n- **Comparative Matrix**: Side-by-side plan ranking with trade-off commentary\n- **Flagged Items**: Any data gaps, assumptions made, or items requiring [VERIFY] follow-up\n\n## Quality Checks\n\n- Confirm all cost-sharing parameters (deductible, coinsurance, copay, OOPM) are captured for both in-network and out-of-network tiers\n- Verify AV calculations use the correct methodology and plan year assumptions\n- Ensure utilization scenarios reflect realistic claims distributions (not just arbitrary multiples)\n- Check that premium comparisons use consistent contribution assumptions (gross vs. net of employer subsidy)\n- Validate network data is current — provider directories can be 60–90 days stale\n- Confirm reinsurance terms match the contract period and claims basis (paid vs. incurred)\n- Flag any state-mandated benefit requirements that could affect plan design comparability [VERIFY: essential health benefit benchmark varies by state]\n- Mark all jurisdiction-dependent regulatory references with [VERIFY]\n",{"name":5,"tags":45,"language":31,"metadata":46,"description":7},[37,21],{"author":47,"skill_modes":48,"document_types":50,"practice_areas":52},"casemark",[49],"Analysis",[51],"Analysis Report",[53,54,55],"Insurance","Actuarial Science","Reinsurance","main","b22eca2e974f918ce591c5b2bd829fb7510e0191","Skills\u002Fanalyzing-health-insurance-plans",18,"https:\u002F\u002Fgithub.com\u002FFDU-INS\u002FInsurance-Skills","https:\u002F\u002Fgithub.com\u002FFDU-INS","Fudan University Department of Risk Management and Insurance","2026-07-12 12:54:34",{"source":8,"skillName":5,"commands":65,"prompt":75,"zipAvailable":76},[66,69,72],{"tool":67,"command":68},"npx","npx skills add FDU-INS\u002FInsurance-Skills --skill analyzing-health-insurance-plans",{"tool":70,"command":71},"bunx","bunx skills add FDU-INS\u002FInsurance-Skills --skill analyzing-health-insurance-plans",{"tool":73,"command":74},"pnpm","pnpm dlx skills add FDU-INS\u002FInsurance-Skills --skill analyzing-health-insurance-plans","安装技能，技能地址：https:\u002F\u002Fgithub.com\u002FFDU-INS\u002FInsurance-Skills\u002Fblob\u002Fmain\u002FSkills\u002Fanalyzing-health-insurance-plans\u002FSKILL.md",true,[],[79,107,129,160,182,214],{"skillNo":80,"name":81,"nameZh":6,"description":82,"descriptionZh":6,"repositoryFullName":8,"ownerLogin":9,"ownerAvatarUrl":10,"ownerAccountNo":11,"ownerDisplayName":12,"repositoryNo":13,"starsCount":14,"licenseSpdxId":15,"licenseFileUrl":6,"sourceHtmlUrl":83,"categories":84,"keywords":90,"publishedAt":40},"01M713QW6EGEG0YAD75440GSD0","로인장 (Roinjiang)","Activates when the user needs legal advice, contract review, insurance law consultation, startup legal support, or any legal\u002Fregulatory matter. She is a top-tier in-house lawyer with absolute loyalty to the CEO, specializing in insurance law, financial consumer protection, privacy, contracts, labor law, family law, civil and criminal matters.","https:\u002F\u002Fgithub.com\u002FFDU-INS\u002FInsurance-Skills\u002Fblob\u002Fmain\u002FSkills\u002F로인장 (Roinjiang)\u002FSKILL.md",[85],{"categoryNo":86,"categoryName":87,"taxonomyType":88,"taxonomyTypeDesc":89},"01JBSEEDCAT000000000000037","律师与法务","PROFESSION","适用职业",[81,91,21,92,93,94,27,95,96,29,97,98,99,100,101,102,103,104,105,106],"insurance law","civil","contract","family","review","loyalty","top","contract review","ceo","support","advice","consultation","regulatory","privacy","protection","startup",{"skillNo":108,"name":109,"nameZh":6,"description":110,"descriptionZh":6,"repositoryFullName":8,"ownerLogin":9,"ownerAvatarUrl":10,"ownerAccountNo":11,"ownerDisplayName":12,"repositoryNo":13,"starsCount":14,"licenseSpdxId":15,"licenseFileUrl":6,"sourceHtmlUrl":111,"categories":112,"keywords":113,"publishedAt":40},"01M713QRN8VFMA9VKS6R4DJ2WS","zocdoc-doctor-finder","Use when a user needs to find a doctor, dentist, specialist, therapist, or healthcare provider — especially when they mention insurance, in-network, availability, location, appointments, or booking. Also use for browsing provider reviews, comparing doctors by specialty, or checking if a provider takes their insurance.","https:\u002F\u002Fgithub.com\u002FFDU-INS\u002FInsurance-Skills\u002Fblob\u002Fmain\u002FSkills\u002Fzocdoc-doctor-finder\u002FSKILL.md",[],[114,115,35,116,21,117,118,27,119,120,121,38,122,123,124,125,126,127,25,128],"zocdoc doctor finder","doctor","reviews","browser automation","access","browsing","browser","booking","therapist","computer","availability","for","provider","tool","automation",{"skillNo":130,"name":131,"nameZh":6,"description":132,"descriptionZh":6,"repositoryFullName":8,"ownerLogin":9,"ownerAvatarUrl":10,"ownerAccountNo":11,"ownerDisplayName":12,"repositoryNo":13,"starsCount":14,"licenseSpdxId":15,"licenseFileUrl":6,"sourceHtmlUrl":133,"categories":134,"keywords":140,"publishedAt":40},"01M713QKGV3FTX7EEYWKDM8ENZ","zenmux-context","Answers any question about ZenMux by reading the latest official documentation. Use this skill whenever the user asks about ZenMux product features, API usage, configuration, integration, pricing, models, providers, routing, fallback, streaming, multimodal, structured output, tool calling, reasoning, prompt caching, image generation, video generation, web search, long context, observability, logs, cost tracking, usage analytics, insurance, subscription, pay-as-you-go, invoices, best practices for tools like Claude Code, Cursor, Cline, CodeX, Gemini CLI, opencode, Cherry Studio, Obsidian, Sider, Open-WebUI, Dify, Neovate, GitHub Copilot, OpenClaw, CC-Switch, Immersive Translate, Studio Chat, architecture, benchmarks, FAQ, contact, privacy, terms of service, compliance, or any other ZenMux-related topic. Also trigger when the user writes in Chinese about ZenMux: 文档, 使用指南, 快速开始, API 参考, 最佳实践, 模型路由, 供应商路由, 订阅, 按量计费, 可观测性, 帮助, 常见问题, 接入指南, 配置. Trigger on phrases like \"how to use ZenMux\", \"ZenMux docs\", \"ZenMux API\", \"ZenMux integration\", \"ZenMux 怎么用\", \"ZenMux 接入\", \"ZenMux 配置\". Even if the user doesn't say \"ZenMux\" explicitly but asks about LLM API aggregation, model routing, provider fallback in a context where ZenMux is the project being worked on, this skill should activate.","https:\u002F\u002Fgithub.com\u002FFDU-INS\u002FInsurance-Skills\u002Fblob\u002Fmain\u002FSkills\u002Fzenmux-context\u002FSKILL.md",[135],{"categoryNo":136,"categoryName":137,"taxonomyType":138,"taxonomyTypeDesc":139},"01JBSEEDCAT000000000000016","图像与多媒体","SCENARIO","使用场景",[141,142,143,144,21,145,146,147,148,149,150,151,152,153,154,155,156,157,158,159],"context","zenmux context","Video","chinese","project","web search","translate","search","open","question","pay","image","you","activate","architecture","logs","streaming","cherry studio","how",{"skillNo":161,"name":162,"nameZh":6,"description":163,"descriptionZh":6,"repositoryFullName":8,"ownerLogin":9,"ownerAvatarUrl":10,"ownerAccountNo":11,"ownerDisplayName":12,"repositoryNo":13,"starsCount":14,"licenseSpdxId":15,"licenseFileUrl":6,"sourceHtmlUrl":164,"categories":165,"keywords":166,"publishedAt":40},"01M713QHWTBG634BCBV7NBJME1","workers-comp-guide","Guide workers compensation compliance and claims management.\nTRIGGERS - Use when user needs help with workers-comp-guide related tasks.","https:\u002F\u002Fgithub.com\u002FFDU-INS\u002FInsurance-Skills\u002Fblob\u002Fmain\u002FSkills\u002Fworkers-comp-guide\u002FSKILL.md",[],[167,168,169,170,171,21,172,173,25,27,174,29,175,176,177,178,179,180,181],"workers","comp","workers comp","workers comp guide","guide","triggers","workers-comp","tasks","claims management","claims","compliance","help","compensation","management","user",{"skillNo":183,"name":184,"nameZh":6,"description":185,"descriptionZh":6,"repositoryFullName":8,"ownerLogin":9,"ownerAvatarUrl":10,"ownerAccountNo":11,"ownerDisplayName":12,"repositoryNo":13,"starsCount":14,"licenseSpdxId":15,"licenseFileUrl":6,"sourceHtmlUrl":186,"categories":187,"keywords":197,"publishedAt":40},"01M713QF45VMV1685AFNF1GPMA","weekly-kpi-report","Generate McKinsey-style board presentation PPTs from weekly auto insurance data. Automatically calculates 16+ KPIs, creates executive-level slides with actionable insights, and supports week-over-week comparisons. Use when user uploads insurance cost data (Excel\u002FCSV) and requests board report, weekly presentation, executive briefing, or mentions keywords like 董事会汇报, 周报PPT, 经营分析演示, McKinsey-style reports.","https:\u002F\u002Fgithub.com\u002FFDU-INS\u002FInsurance-Skills\u002Fblob\u002Fmain\u002FSkills\u002Fweekly-kpi-report\u002FSKILL.md",[188,191,194],{"categoryNo":189,"categoryName":190,"taxonomyType":138,"taxonomyTypeDesc":139},"01JBSEEDCAT000000000000003","演示文稿",{"categoryNo":192,"categoryName":193,"taxonomyType":138,"taxonomyTypeDesc":139},"01JBSEEDCAT000000000000004","电子表格",{"categoryNo":195,"categoryName":196,"taxonomyType":88,"taxonomyTypeDesc":89},"01JBSEEDCAT000000000000034","行政与办公人员",[198,199,200,39,201,21,202,203,204,205,27,206,207,208,209,210,211,212,25,213],"weekly","weekly kpi report","kpi","xlsx","actionable","insights","briefing","auto","board report","reports","generate","演示","data","presentation","slides","uploads",{"skillNo":215,"name":216,"nameZh":6,"description":217,"descriptionZh":6,"repositoryFullName":8,"ownerLogin":9,"ownerAvatarUrl":10,"ownerAccountNo":11,"ownerDisplayName":12,"repositoryNo":13,"starsCount":14,"licenseSpdxId":15,"licenseFileUrl":6,"sourceHtmlUrl":218,"categories":219,"keywords":223,"publishedAt":40},"01M713QA9WJDHMNVTTY1ENRKVB","wealth-advisory","Wealth management and financial planning for HNW and UHNW clients. Activate when the user\nmentions wealth management, financial planning, retirement, estate planning, tax planning,\nGRAT, IDGT, trust, asset allocation, withdrawal rate, Monte Carlo simulation, goals-based\ninvesting, tax-loss harvesting, Roth conversion, insurance, annuity, mortgage strategy,\nconcentrated stock, family office, direct indexing, 529 plan, charitable giving, donor-advised\nfund, private foundation, or asks about personal finance strategy, inheritance, long-term\nfinancial planning, or UHNW advisory.","https:\u002F\u002Fgithub.com\u002FFDU-INS\u002FInsurance-Skills\u002Fblob\u002Fmain\u002FSkills\u002Fwealth-advisory\u002FSKILL.md",[220],{"categoryNo":221,"categoryName":222,"taxonomyType":88,"taxonomyTypeDesc":89},"01JBSEEDCAT000000000000040","财务",[224,225,21,226,227,27,154,228,229,34,230,231,232,233,234,235,236,237,238,239],"wealth advisory","advisory","stock","inheritance","conversion","indexing","simulation","personal finance","rate","allocation","asset","direct","personal","investing","trust","planning"]