Description: PBMs are positioned in the healthcare delivery system as the only entity that is not regulated for profitability. The Commercial Fully Insured Health Insurance Plans are heavily regulated by the State Insurance Commissioner who allows only 2%-3% profit margin. The self-funded Health Plans are regulated by ERISA fiduciary responsibility that prohibits excessive compensation. PBMs are classed as a service provider and are not regulated by either. This allows PBMs to implement large, unreasonable mark ups for profit. PBMs are massive commercial entities, states are trying to sue under antitrust law. PBMs found a sweet spot in the regulation. Large Insurance Carries understood that and either acquired large PBMs or merged with them. It is likely that a combination of measures will be needed to regulate PBMs. The most direct approach would be for Congress to pass a law establishing PBM as a fiduciary under ERISA just like an “investment advisor” providing advice for a fee. Establishing PBM as a fiduciary will help Courts and other Federal Agencies ensure that PBMs do not unfairly retain rebates and inflate the prices of Rx drugs sold to employer health plans, and the US population in general.

Description: Discussion of recent developments in the taxation of noncoordinated benefits such as fixed indemnity, hospital indemnity, and specified disease insurance policies. Developments include a recent Chief Counsel Advice Memorandum and proposed triagency rulemaking that would impact non coordinated benefits.

Description: The momentum in value-based care has produced an opportunity for actuaries to become pioneers in health care

Description: "During the pandemic there has been provider burn out, early retirement, hospital consolidation, and lack of staff in step down facilities. It is taking longer to get appointments. Take a look at the impacts of this andat how this can affect quality ratings in Medicare. You can also explore meeting quality incentives in Medicaid and how the current requirements for these plan to say they have adequate networks. Will the provider shortage have an effect upon actuarial rate certifications? If so, how? Are there any forecasts for how long this shortage will last? What are the impacts to care giving to the Seniors and Medicaid beneficiaries as well as plan design changes? Those who are intermediate level Medicaid and Medicare actuaries are encouraged to attend. By attending this session, you will be able to: Have a good understanding of the current Medicare and Medicaid situation and its impacts Understand strategic ideas of how to keep quality of care and access to care available"

Description: It's your first full day of productive learning! Start it off right with a delicious breakfast and warm welcome.

Description: How does where you live impact your health? The following research considers this question through the lens of social determinants of health (SDOH), which are factors relating to where you live or work that may impact your health. In the United States, there are geographical differences in SDOH which contribute to wide disparities in health status and outcomes. In particular, individuals who are negatively affected by SDOH may have an increased burden of disease, leading to a relatively high total cost of care and worse quality of life.

Description: Explore the role of inflation across health products, including medical plans, disability, and long-term care. Explore various drivers of cost trends, wage increase, and cost of care. Understand their role in the pricing and valuation of a product and how to manage the risk.

Description: This report is targeted to actuaries that are interested in identifying the adverse human health outcomes resulting from anthropogenic climate change. This is accomplished by providing a detailed framework to evaluate the impact of extreme heat on human health and identify the role that anthropogenic climate change has on extreme heat events. Although this document is designed around extreme heat, the concepts can be expanded to other climate-related events. As the primary focus of actuarial research is to promote human health and minimize the preventable economic burden, this document also provides recommendations to mitigate against excess heat related illness (HRI) due to extreme heat.

Description: A divisive confrontation over health care pricing is almost inevitable over the next few years. What will ultimately happen is a political decision, not an actuarial one—but it will have major consequences for the trend in health care costs and the divergence between public and private insurance premiums.

Description: The Society of Actuaries will host two great events for the health actuarial community, bringing together the industry’s leading actuaries, analysts and professionals to network and discuss impacts of the latest marketplace factors and trends.