Description: Applying Diagnosis-Based Predictive Models that use medical and pharmacy claims to measure expected costs for Group Underwriting. Issue No. 46.

Description: Update on Affordable Care Act topics, including Section 1332 waivers, Association Health Plans, silver loading and cost sharing reductions.

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: Description of the upcoming activities for the Health Section.

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 big event of 2023 is the launch of multiple Humira biosimilars, which began in January with the arrival of Amgen’s Amjevita on the market. The launch of Amjevita kicks off the process of changing the specialty drug marketplace in the United States. The expectation of the full impact of this big event is very hopeful, but there is still uncertainty several months after its beginning. Humira is the highest-selling drug in the world and has been since 2013 (Figure 1)—except for when COVID-19 projects temporarily surpassed it. The world is eagerly awaiting the launch of multiple biosimilar drugs to compete with Humira and hopefully bring more competitive pricing to the benefit of payers and patients everywhere.

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: This article suggests actuaries evolve from technical experts to strategic influencers by strengthening their communication skills. It highlights why data alone isn’t enough—actuaries must clearly convey insights, make recommendations, and tailor messages to business audiences. With practical tips and communication shifts, the piece helps actuaries present their work with greater impact. Written by an experienced actuarial leader, it offers real-world relevance for professionals aiming to drive decisions and add strategic value in healthcare and insurance settings.

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: Discussion of issues from The Credibility Task Force for Health Coverage. From Health Section News, June 1998, Issue No. 35.