Description: Any analysis of risk assessment and risk adjustment must pay special attention to large claims. If the goal of risk adjustment is to motivate carriers to be efficient,, as opposed to motivating carriers to select the best risks,then finding a solution to the problem of compensating carriers fairly for these high-cost claimants is an absolute necessity. From A Comparative Analysis of Methods of Health Risk Assessment, M-HB96-1.ese

Description: Employer and payers need to actively seek change in the system of mental health care deliveryoperational, clinical, and financial change. From Financing Chronic Care Monograph, M-HB05-1.

Description: This article will consider several issues arising from ACO budgeting and pricing of stoploss coverage, including: 1) attribution of members; 2) claim carve outs; 3) ambiguous stoploss terms; 4) providers gaming the system and 5) credibility of data.

Description: This paper highlights the menace of overweight and obesity which are on the rise. Health care systems and insurance industries are directly affected. Liability claims are on waiting. The food related damage claims are costly. Insurers are therefore driven to find a solution: classify overweight and obesity as a group, adjust their premium to reflect the cost, and justify the classification and the adjustments.

Description: In this paper, fuzzy sets - collections of objects whose boundaries are not precisely defined - are used to model the selection process in group health insurance. Both single and multiple options plans are discussed. Discussions of this paper are included.

Description: CLASS Act and ACA

Description: The winner's curse, applied to Affordable Care Act plan pricing.

Description: This article begins with a comparison of the commercial risk adjuster to the exisiting Medicare model, and goes on to discuss why the existing strategies employed by health plans will not work in a risk adjusted environment. The article elaborates on the importance of diagnosis coding, controlling member mix, and care management in order to mitigate risks and gain from newly created opportunities.

Description: This session is about health risk adjustments. Health care reform issues and Society of Actuaries research activities will also be discussed. From Record of Society of Actuaries Vol. 20, No. 3A.

Description: Panelists discuss the following managed care topics: · Design issues/pros and cons e.g., self-directed health-care model · Provider reimbursement methodologies · Consumer and regulatory issues · Insurance and reinsurance pricing and underwriting issues · Catastrophic claims · Risk-based capital repercussions · Defined contribution health plans From the Record of the Society of Actuaries, Volume 27, No. 1, Session 61