Description: ACA Impact on Employers

Description: This session will explore the national landscape of state Medicaid risk adjustment program design & application and the key differences that drive effective managed care organization program management. Risk adjustment is a mechanism to adjust capitation rates between Managed Care Organizations to account for population morbidity differences. Although many states utilize this mechanism, the application of risk adjustment can vary significantly across states. The primary differences include populations, risk score models and data collection. These state application nuances affect the strategies and tactics utilized by MCOs for effective risk adjustment program management including provider financial alignment, encounter data submission and the capture of accurate diagnosis codes. The session is intended for Medicaid Managed Care Actuaries working to develop or support comprehensive risk adjustment program management functions.

Description: Medicaid and the ACA

Description: Read the March 2017 issue of Health Watch, published by the Health Section. Practical information for actuaries, articles impact sections, section activities.

Description: Read the June 2018 issue of Health Watch, published by the Health Section. Practical information for actuaries, articles impact sections, section activities.

Description: This article compares three potential approaches to determining new coefficients for health-based risk scoring models: full recalibration, p-value credibility weighting, and penalized ridge regression.

Description: Read the February 2018 issue of Health Watch, published by the Health Section. Practical information for actuaries, articles impact sections, section activities.

Description: Healthcare risk adjustment methodologies have become increasingly complex, largely due to the belief that complexity enhances accuracy. However, a disconnect exists between how healthcare risk is assessed and how payments are adjusted. This article explores the stark difference between measuring the accuracy of a risk assessment model at a member level, and that of a risk adjustment mechanism at the health plan level. I show that a highly simplified approach that does not use diagnosis codes can have similar accuracy on risk adjusted payments to models that do. These findings suggest that accuracy is not a barrier to developing simpler risk adjustment methodologies, which can improve payment accuracy and reduce the financial incentive for coding diagnoses.

Description: Risk adjustment is used to adjust the revenue stream to health insurers that sell ACA eligible plans and Medicare Advantage plans. This article compares and contrasts these risk adjustment programs.

Description: The ACA’s Medical Loss Ratio Provisions