Description: The medical scheme approach adopted by several African countries has failed to meet the needs of those in informal employment and rural communities. This is partly due to affordability amongst these individuals as well as a lack of awareness of how healthcare financing products work. Community based healthcare organisations have achieved greater levels of success in this regard by carefully incorporating the peculiarities of communities in benefit design and involving community members in the management of these healthcare solutions. There are lessons to be garnered from the countries where these have been implemented with some level of success. Even as countries aim towards universal health coverage, observing the unique needs of different communities within a country is essential to ensure resources are utilised efficiently and that healthcare needs are targeted effectively.

Description: As actuaries in health care, we spend most of our time focused on reviewing claims, enrollment and clinical data. That information is captured while patients are in health care facilities. Yet most people spend only a small fraction of their time in these facilities. This article explores what types of data are available to actuaries the provide a more holistic view of the member so that a members physical and emotional needs, the social determinants of health can be taken into consideration along with their clinical needs. Two uses cases are presented so actuaries can see how these types of analyses can be leveraged to improve clinical, operational, and financial performance of risk bearing health entities. Understanding the customer (member) not just the patient enables actuaries to provide new insights and values to our stakeholders across a wide range of business and risk applications.

Description: The ACA’s Medical Loss Ratio Provisions

Description: Discussion of developments with regards to addressing major medical care needs since 1959, including the passage of Medicare.

Description: September’s Actuary contained an excellent summary by Drew Davidoff of renewal rating for small group medical business. Among the techniques he describes are age, sex, and area rating, experience rating using credibility, experience rating using tiers, examination of the diagnoses in the claim file, and initial and reentry medical underwriting.

Description: Feature article with helpful hints on video conferencing and more!

Description: Examines the trends affecting the distribution system for the industry's products, and the regulatory and tax environment in which life companies operate. Also looks briefly at the state of competition in the industry.

Description: This paper describes a new major medical policy from The Equitable. The author describes the policy and discusses anticipated claims experience and the calculation of gross premiums. From Transactions of Society of Actuaries 1955 Volume 7, Number 17.

Description: This is a discussion of the paper, Gross Premiums for Individual and Family Major Medical Expense Insurance by Morton D. Miller. From Transactions of Society of Actuaries 1955, Vol. 7, No. 19.