Description: This presentation from Session 8L of the SOA 1996 Colorado Springs Meeting is about analyzing the effectiveness of health care measures as reported by managed care organizations. The discussion focuses on HEDIS, a standardized definition for producing health plan report cards, primarily aimed at health maintenance organizations [HMOs]. From the Record of the Society of Actuaries, Vol. 22, No. 2.

Description: "The always popular Medicaid Hot Topics session is back with discussions from an expert panelist on the most riveting Medicaid topics of the year. These could include the following: • ACA court battles - what are the potential impacts on Medicaid? • CMS continues to open the door for state flexibility - just what can states now do differently?• Where are we on Medicaid work requirements? • How will the changes to the mega-rule impact Medicaid?• High cost drugs and how states are sharing risk for them (carve-out, risk pools, risk sharing)• And more current topics of interest to Medicaid actuaries!Medicaid is dynamic and it is difficult to stay up to date on all of the changes. This session provides insightful discussion into the major changes that impact actuaries and their companies or state clients"

Description: The presenters will cover the variation in risk adjustment approaches used across state Medicaid programs and compare them to other Federal programs. Additionally, recent developments, such as the use of OCR to extract data from medical charts for risk adjustment, will be discussed.

Description: Enterprise Risk Management is often thought to be synonymous with managing an insurance company toward financial objectives with a focus on insurance-specific risks. Some might argue though that operational risks are the crux of all risks confronted by an insurance company and ultimately drive the company’s outcomes.Operational risk is the risk of impact on financial outcomes due to operational events, involving internal systems, personnel, procedures or controls, and also external events. Operational risk exists in all business activities, covering fraud, human error, accounting errors, legal actions and system failures. All of these activities could occur during the course of conducting day-to-day business operations. Additionally, insurance executives must consider the pace of change in the external environment and potential impacts on their business. This presentation is focused on operational risks, current and emerging, faced by health insurance companies.