Description: This article discusses some of the most important considerations in implementing risk adjustment within a Medicaid Managed Care program. From Health Watch, January 2008, No. 57.

Description: Provider Excess is an insurance coverage offered to health care provider organizations that have a capitation agreement with a manged care organization. From Reinsurance Section News, November 2007, Issue No. 61.

Description: this article provides an overview of coverage and claim trends for managed care medical excess of loss insurance and reinsurance programs. it addresses features such as deductible, maximum benefit, inside limits , comprehensive versus non- comprehensive , and claims by diagnosis for commercial , Medicare and Medicaid risk. It also reviews cost containment support programs for catastrophic claims .

Description: This article describes methodologies for detection and deterrence of Medicare fraud. It also describes the validation of PRIDIT for fraud detection in Medicare.

Description: Report from research project that reviewed and inventoried the range of quality and efficiency measures that demonstrate the performance of hospitals and physicians. Besides outlining key areas of consideration for quality and efficiency measurement, this report also describes future opportunities for actuaries and other health professionals interested in this evolving area. The inventory part of the report is in a separate document.

Description: Panelists discuss different aspects of self-selection among Medicare options. From the Record of the Society of Actuaries, Vol. 24, No. 2.

Description: This article explores the changing risk profile between the transitional Affordable Care Act (ACA) period (2014-2016) and under the final ACA period (beyond 2017) for the individual market. Actuaries are in a unique position to help facilitate the change from the current ACA period to the final period when health plans will have to take on substantially more risk.

Description: Discussion of the economics of a possible H5N1 pandemic, and its impact on Life, Health, and Property and Casualty insurers, in terms of areas of risk, especially underwritng risk, operations risk, and market risk.

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: Article provides a market scan of recent state proposals for Medicaid work requirements as well as measures the impact to enrollment in different states.