Description: On December 21, 2018, the Centers of Medicare & Medicaid Services (CMS) released the final rule for Accountable Care Organizations (ACOs) in the Medicare Shared Savings Program. 'Pathways to Success' makes sweeping changes and will push ACOs to assume financial risk more quickly. This session will discuss the key changes in the final rule, reasons why providers would remain in the program while being forced to downside risk, and how actuaries can add value to providers who will be taking on millions of dollars of risk in the coming years.

Description: 2014 marked a new beginning for small group(SG) health insurance market ushered in with adjusted community rated products priced from a single risk pool. It was anticipated that the mandated pooling of the risk would result in higher rates, especially for healthier groups. It is the aim of this article to show whether that view bears out in the actual market rates and if it is higher, then by how much. The article provides a point in time(1st quarter 2025) comparison of premium rates under two segments of the small group market, namely Qualified Health Plans(QHP) available under the small group ACA market versus self-insured Multiple Employer Welfare Arrangements(MEWA) plans.

Description: This is Part 2 of 2 on changes affecting Medigap insurers. It focuses on marketing and regulatory differences between Medigap and Medicare Advantage that affect the competitiveness of Medigap plans.

Description: Numerous behavioral finance theories have emerged in recent years, many of which apply to insurance. The presenters look at key theories and their use in explaining, predicting and inducing behavior from the perspective of the health insurance customer journey.

Description: ReMark's Global Consumer Study delivers 10 key insights to empower customers. Insurers can design products that meet customers' needs and enhance client experiences and add significant value to their business. At the same time with new products being launched seemingly continuously, it is important to take a step back and assess risk throughout the product management cycle.

Description: This report outlines a framework for interpretable machine learning algorithms for detecting fraud in health insurance. It discusses the challenges of using black-box machine learning models in the insurance industry and proposes various interpretable methods to enhance transparency and understanding.

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.

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: What is the difference between a Single-Payer and Universal Health Care System, and how could the U.S. implement a system that would reduce the growth of medical costs while increasing quality.