Description: This article details the medical stop-loss coverages purchased by HMOs, small insurers and providers taking delegated financial risk in payor agreements. Along the way we will identify strategies purchasers often use to save money on medical stop-loss.

Description: Introduce basic concepts of the Health Risk-Based Capital and show case a few strategies around Risk-Based Capital.

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: Two years ago, before COVID-19 changed everything about how we provide and receive health care, telehealth was largely provided by third-party vendors to treat a narrow range of acute one-and-done conditions. The value proposition was simple: a fast and easy member experience would drive satisfaction and engagement; high member satisfaction and engagement would drive health plan savings and member retention. Clearly, from the perspective of utilization, telehealth—as a viable alternative to in-person care during a pandemic—worked. And with COVID-19’s nudge—or was that a push?—toward cultural acceptance, the health care system is in a better position to capitalize on telehealth’s original promise of expanded access, lower cost and better outcomes than it was two years ago. But in the wake of the pandemic, it is just as clear to us that if telehealth is to live up to its full potential, some changes are needed. The rest of this article presents five ideas for improving the delivery of telehealth going forward.

Description: Python has become the fastest-growing major programming language in the world. It has surged in popularity over the last decade, following the development of its industry-leading capabilities in data science, machine learning and artificial intelligence, and it is now one of the most globally popular and widely used languages. In this article, I discuss some of the reasons for its popularity and explain why many actuaries and insurers have started using Python.

Description: Actuaries with Medicare expertise regularly receive information specific to either Part C or Part D, but a key component of successful bid preparation is effective coordination between these two programs. This article explores pricing and regulatory common ground between Part C and Part D bids to aid actuaries as they guide decisions impacting both benefits.

Description: ACA risk adjustment is intended to "bridge the gap" between allowed rates and actuarial rates. If risk adjustment methodology is not bridging that gap & becomes an additional input to pricing formulae, it is not serving its intended purpose.

Description: Response to March 2021 Practice Note on ASOP 6

Description: In 2018, the Financial Accounting Standards Board (FASB) adopted significant revisions to the U.S. GAAP insurance accounting literature, via Accounting Standards Update (ASU) 2018-12. The title of ASU 2018-12 is “Targeted Improvements to the Accounting for Long-Duration Contracts,” and as a result a common acronym for ASU 2018-12 is LDTI (long-duration targeted improvements).

Description: Actuaries are leveraging predictive modeling and machine learning more and more as they strive to provide greater value to their stakeholders. Actuarial standards of practice provide guidance around modeling and data. The world has changed significantly over the last few years, so it is important these models be tested for fairness as well as any statistical biases. This article addresses some of the key issues actuaries need to be aware of as Corporations and society work through the responsible us of this technology and underlying data.