Description: Methods and assumptions used in the valuation of savings by external care vendors

Description: 1994 SOA Meeting, San Antonio. This session on physician reimbursements focused on arrangements that might be offered by managed care companies, such as HMOs. It included an overview of key definitions, concepts, and incentive compensation arrangements.

Description: The Society of Actuaries Research Institute developed a new study to explore pharmacy financing. The goals of the SOA related to this research are to identify opportunities to increase transparency, encourage competition, align stakeholder incentives and mitigate increases in total cost of care. The research uses a value-based methodology.

Description: This session will explore the national landscape of state Medicaid risk adjustment program design & application and the key differences that drive effective managed care organization program management. Risk adjustment is a mechanism to adjust capitation rates between Managed Care Organizations to account for population morbidity differences. Although many states utilize this mechanism, the application of risk adjustment can vary significantly across states. The primary differences include populations, risk score models and data collection. These state application nuances affect the strategies and tactics utilized by MCOs for effective risk adjustment program management including provider financial alignment, encounter data submission and the capture of accurate diagnosis codes. The session is intended for Medicaid Managed Care Actuaries working to develop or support comprehensive risk adjustment program management functions.

Description: This paper investigates the accuracy of loss reserves by comparing some reserves with the actual results five years hence. The ultimate purpose was to provide an estimate of the amount of variability which cannot be explained by listed factors. The resulting amount of variability gives an indication of the amount required for a provision for adverse deviation. From Actuarial Research Clearing House 1991, VOL. 1

Description: 1993 SOA Spring Meeting, San Diego. This session is about point-of-service plans, overview of current enrollment statistics/ tends, in-network and out network utilization patterns, trends in benefit design, employer/benefit consulting demands and employee/employer satisfaction.

Description: This article describes the four keys to successful worksite marketing: 1. Onsite selling either with group meetings or one-on one using professional enrollers. 2. Use a process that has been proven successful. 3. Gain employer sponsorship/commitment/endorsement. 4. Ensure your insurance company is committed as evidenced by high quality service from issue on through the life cycle of the policy.

Description: 1994 SOA Meeting, San Antonio. This session was about provider network building in nonmetropolitan areas. Question addressed: 1. How can an effective delivery system be built to serve rural areas? 2. What influence will health care reform have on such systems? 3. Does a single-payer system make sense for such populations? 4. How does health care reform impact nonmetropolitan markets?

Description: On average, contracts receiving their first star rating receive 3.20 stars, compared to existing or established contracts receiving 3.90 stars on average. This 0.70 disparity in quality ratings creates significant hardship on new contracts when this lower star rating decreases their payments in the following calendar year. This article explores the disparity in Medicare Advantage Star Ratings between contracts receiving their first star ratings (“New” contracts) and existing contracts, including: 1. Understanding what happens to Medicare Advantage Payments when contracts receive lower star ratings? – What is the Star Rating cliff and why does it matter to new contracts? 2. Explaining when a contract receives their first star rating and how much enrollment this requires – When does the Star Rating cliff occur? 3. Noting which specific star measures “New” contracts struggle with, including those contracts under large parent organizations, contracts with rapid growth, and all other new contracts. – How can my contract avoid the Star Rating cliff?

Description: 2003 Valuation Actuary Symposium, San Diego, CA. The panel discussed the current challenges in the health reinsurance marketplace. Topics included traditional quota share reinsurance, employer and provider stop-loss coverage, difficulties in obtaining reliable and credible data from a ceding carrier and terrorism reinsurance.