Description: Letter from the Editor Greetings to All Health Actuaries! by Jeffrey D. Miller from Health Section News, April 2001, Issue No. 40.

Description: The coming wave of biosimilars could dramatically affect prescription drug costs and benefit strategies over the next several years. The launch of many Humira biosimilars in 2023 is the Big Event that will largely determine the impact of the biosimilar wave. Payers have many decisions to make about coverage and formulary tiers. What factors will drive payer decision-making?

Description: This article discusses the court cases dealing with the severability of the individual mandate from the Affordable Care Act. Severability is related to essentiality, and actuarial input was relied upon to determine essentiality. The article concludes with lessons that actuaries should learn from the legal proceedings.

Description: Read the April 2020 issue of Health Watch, published by the Health Section. Practical information for actuaries, articles impact sections, section activities.

Description: The impact of Medicare payments on retiree medical. Issue No. 46.

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: Source: This document is a whitepaper sourced from a health insurance industry analysis. It provides a detailed overview of the evolution and strategic importance of voluntary benefits within employer-sponsored health plans in the United States. Intent: The paper aims to inform healthcare stakeholders—particularly employers, insurers, and HR professionals—about the role of voluntary benefits in filling coverage gaps left by major medical plans. It outlines the historical development, market drivers, regulatory context (especially post-ACA), and future trends, with a focus on personalization, digital integration, and financial protection. Value: This resource offers practical insights and strategic guidance for enhancing benefits design and employee engagement.

Description: Read the June 2019 issue of Health Watch, published by the Health Section. Practical information for actuaries, articles impact sections, section activities.

Description: In April 2018, the Centers for Medicare & Medicaid Services (CMS) published a revised definition of primarily health related (PHR) benefits as applicable to Medicare Advantage (MA) organizations.

Description: ACA risk adjustment has now been in play for years. The original intent of risk adjustment was to help stabilize the market through measuring risk levels of each issuer. However, the risk adjustment program may have introduced additional uncertainty due to annual market shifts and model changes, making risk adjustment estimation is a difficult task. This article analyzes the results over time, including impacts from market changes and model changes.