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: The article provides insights about the need for revolutionary actuaries in Saudi Arabia due to the reform that is happening across the kingdom under all sectors. Then I talk briefly about the health sector and the transformation that is happing in the sector, and how qualified health actuaries can contribute to this health reform.

Description: This article is the abstract from a paper that provides methods and formulas for calculating active life reserves for credit insurance.

Description: This article is about the relationship of brand advertising to direct marketing and how to bridge the gap.

Description: This paper is a primer for actuaries with limited experience in accessing and using public data sets. From Small Talk Newsletter, November 2005, Issue No. 25.

Description: Adam Barnhart and Stephanie Moench, the co-charis of the new Health Community, announce the official community launch, which merges the former Long-Term Care and Health Section Councils into a single, unified group. The community aims to foster professional development through high-quality education, research, and collaborative networking for actuaries. To ensure a personalized experience within this large organization, members are encouraged to join one of more than 12 specialized subgroups. These groups offer focused discussions and expert insights via regular topic calls and private listservs. Under the new community model, members have flexible opportunities to contribute without needing to hold an elected position. Volunteers are sought for content creation (articles, podcasts, and webcasts), subgroup leadership, and industry research projects. Members can browse available subgroups and volunteer opportunities through the Society of Actuaries (SOA) website. By integrating these legacy sections, the Health Community strives to build a vibrant, innovative future for its members at every career stage.

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.