Melissa Huenefeldt, FCAS, MAAA, CPCU, ARM

Price Transparency in Indiana for 2 Large Health Systems: IU Health & Parkview Focus is ER visits comparing Anthem PPO and UHC PPO contracted rates benchmarking to Medicare Adjusted Rates CPT 99283 Anthem Range % of Medicare: 366%-520% UHC Range % of Medicare: 410%-1,119% CPT 99284 Anthem Range % of Medicare: 639%-794% UHC Range % of Medicare: 631%-1,011% CPT 99285 Anthem Range % of Medicare: 440%-551% UHC Range % of Medicare: 490%-727% Additional Insight: CPT codes 99285, 99284, and 9923 generated $339,301,095 in billed charges through July 2024 YTD for IU Health System All three CPT codes were in the top 13 of utilization and generated the most in billed charges #employeebenefits #pricetransparency

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As I review a 2021 letter to a state client, I lament the continued references to the ‘CSR Defunding impact’ as "silver loading", & the resulting confusion of state legislators & misframing of holistic actuarial professionalism concerns. https://lnkd.in/gvy5WmCB "Detractors of premium alignment sometimes resort to disingenuous arguments to confuse the situation. For example, some suggest that premium misalignment is merely the result of an emergency response to CSR Defunding, & therefore excusable because it was not anticipated by the ACA. That is clearly a false assertion; as illustrated, premium misalignment began years before CSR Defunding was a consideration. In fact, the impact of CSR Defunding (in 2018) was a little more than an offset to the degree of premium alignment that had already occurred. CSR Defunding has complicated the understanding of premium misalignment, but it did not cause it. Premium misalignment was present before CSR Defunding occurred, it is present now, and it will continue if CSR funding is restored. States should not be fooled by this conflation." 'Due to silver loading, it appears that current metal-level premiums are misaligned & do not reflect coverage generosity.' https://lnkd.in/gEDhNgXx Charles Miller puts this way, "The problem of underpriced silver plans that effectively violates single risk pool requirements is independent from the ‘silver-loading’ debate & existed prior to CSR defunding. However, the question of how to legally & compliantly fund CSR expenses in the absence of appropriation has muddied the issue & created an opportunity for those who support violating the single risk pool requirements to try to conflate these independent issues.” Despite the harmful impact to ACA consumers via higher premiums & lower derived subsidies, many prominent voices openly champion ‘relaxed rating compliance’ in ACA markets & speak transparently of the policy efficacy & market benefits of not aligning premiums with coverage generosity as required by the ACA’s single risk pool guidelines. They cite reasonableness, distribution of ‘healthy enrollees’, ‘experience rating’, ‘pricing differentiation’ & eliminating cross-subsidization, ‘lower risk transfers’, behavior of ‘members in silver plans’, metal level experience, ‘regulator responsibility to choose among enforcement strategies based at least in part on their consequences’, compliance causing ‘members to choose gold plans’, competing at right metal levels, fragile exchanges, & people getting ‘money’s worth’, but the ears of the regulatory community are afflicted by those who have catalyzed the mischaracterization of actuarial integrity related to single risk pool compliance as ‘Silver Loading Policies’. https://lnkd.in/gErG7NW8 Opinions are mine alone & not those of Axene Health Partners, LLC.

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The discussion surrounding weight loss management and obesity is constantly evolving with an increased focus on prescription drugs. In this SOA podcast, Jackie Lee and I discuss GLP-1s and why actuaries and other healthcare professionals need to continuously monitor their growth.

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In addition to cutting benefits, Humana mentioned exiting certain counties and plans. This will create risk for Medigap insurers as the most costly MA members may be eligible for Medigap Guaranteed Issue rights. Loss ratios on GI business are often 15%+ higher than on the rest of the block. Some of the highlighted states can be more challenging for rate increases creating additional risk for the most competitively priced Medigap carriers.

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CMS released the 2026 MA-PD Proposed Rule this morning. Still going through it, but when I saw "Medical Loss Ratio (MLR)" I had to stop and read. They are proposing making changes to the MLR calculation. The last sentence tells you why and what they're trying to accomplish. Who know what will happen given the change in administration, but interesting to watch. As a reminder.... numerator is the top number in a fraction 😀 -- P.S. -> if you're a leader in the Medicare space sign up for my weekly newsletter "Medicare Market Insights" https://lnkd.in/gmv65ipM

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This is something that cou;d mean some significant effect in the market all over the country, however the reinsurance progream in the state of Minnespta also puts another wrinkle in this! Stay tuned! #thinkingdifferently #cfoinsights #ceoinsights #hr #hrbenefits #employee experience #ESOPCG

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The September 2024 edition of Health Watch includes a review of the Society of Actuaries 2024 Health Meeting, an interview with me on the No Surprises Act, and an article on the nuts of bolts of pharmacy benefit managers. Check it out: https://lnkd.in/gAunJ8qj #soahealth #actuaries

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Lots of Star Ratings changes being measured in 2024 - check out our summary linked below!

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Who: Ben Krambeck Where: West Des Moines, IA What: A 60 Minutes-style Interview Why: To share the powerful story of ClaimDOC We hope you enjoy this journalistic look at how ClaimDOC came to be. #rbp #referencebased #medicalpricing #medicalbilling #healthinsurance #insurance #claimdoc #selffunded

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The Power of Captive Insurance Plans for Trucking Companies: Thin margins and unpredictable risks are the norm, and trucking companies are increasingly turning to Captive Insurance to address those challenges. Talk to Alera Group about a captive solution. https://ow.ly/mrbt30sFtLo

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📰 White paper release: Stars in Retrograde – Decoding the 2025 Decline The 2025 Medicare Advantage Star Ratings brought significant changes to the quality landscape, challenging health plans to rethink their strategies. Our latest Milliman white paper authored by Hayley Rogers and Matthew Smith dives into key factors affecting this year’s decline, including: ⭐ Sharp decline in Quality Bonus Payments (QBP): The member-weighted average fell below 3.5% for the first time, impacting revenue. See Figure 1 for number of contracts by change, with more contracts negatively impacted. ⭐ Rising impact of Social Risk Factors (SRFs): Plans with high SRFs saw more substantial rating drops, highlighting the need for targeted quality improvements. ⭐ Legal landscape: Multiple Medicare Advantage organizations are challenging the Star Rating methodology, including issues with transparency and data reliability. ⭐ Market restructuring: Fewer new entrants and increased contract consolidations may signal further Star Rating declines, with profound implications for future quality initiatives. Learn more about these industry-wide shifts and what they mean for healthcare policy and strategy. 📄 Read the full white paper to prepare your organization for what's next. Link in comments

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This piece by Modern Healthcare is spot on (link in comments), and well worth the quick read for any stakeholder in the #medicareadvantage space to ensure you are considering the risks new membership may bring. 📉 We know that many of the national #medicareadvantage organizations pulled out of markets for 2025. They likely were doing so because the areas were under performing or because they didn’t see a path to profitability. 💲 In service areas where MAOs retained plans, many nationals are also not paying commissions in some form or another – and the reason for that is after seeing what competitors are offering, they are worried the membership they may attract will be “poor risks” or that they will be unable to manage these members in the long-term. 👵 For smaller, regional, health insurers who remain in these service areas, they have an unprecedented opportunity to expand market share due to the nationals plan terminations or SARs. ❓ However, smaller, regional, MAOs should stop to question – what does this really mean for us? It will be critically important to understand the new membership MAOs are taking on in 2025 – the characteristics each member brings and if your organization is prepared to manage those members. This may or may not have been something #medicareadvantage organizations planned for in their 2025 bid – but as you are going into 2026 bids, it will be especially important to measure and adjust your 2024 population baseline (used in the 2026 bids) for the new membership you have taken on. If you have any questions on better understanding this dynamic, please do not hesitate to reach out!

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Attending the NAIC meeting in Chicago. Fascinating conversations and presentations, including the one below. #insurance #NAIC #technology #innovation #AI

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As healthcare costs continue climbing 📈 , insurers are leaning harder into "gap-filler" products like critical illness and hospital indemnity insurance. These plans, designed to help workers manage major medical deductibles and co-pays, saw a 10% sales increase in the first half of 2024, totaling $2 billion. Critical illness premiums jumped 17%, while hospital indemnity policies climbed 12%, according to LIMRA data. Why the surge? More employers (37% for hospital indemnity) are offering these voluntary benefits, as flexible regulations and low-risk margins make them attractive to insurers. Players like Lincoln Financial Group Trust Co Inc and Prudential Financial are doubling down, with Lincoln reporting a twofold sales increase in workplace solutions over the past year. The trend underscores a growing reliance on these policies as workers navigate high-deductible plans. While they’re no replacement for comprehensive health coverage, they clearly fill a lucrative niche. #EmployeeBenefits #SupplementalInsurance #HealthcareCosts #CriticalIllness #HospitalIndemnity #VoluntaryBenefits

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Record-breaking heat is becoming the new normal. How is the insurance industry coping? Milliman experts discuss the impact of extreme heat on workers' comp, property, and health insurance. Learn about their research and how the industry is preparing for the future. https://ow.ly/sw4E30sGmG2 #extremeweather #insurance #riskmanagement

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Webinar Announcement: Breaking Bid - What Just Happened? The 2025 #medicareadvantage bid cycle has been a rollercoaster, tackling significant changes to risk models, the #inflationreductionact, #starrating changes, bid resubmissions, unexpected #pdp demonstrations, and potential regulatory uncertainty from the Supreme Court. Join us for an in-depth discussion on these pressing issues and more. Don't miss out on this chance to stay informed and ahead of the curve. Date: Wednesday, September 18 @ 12:00 p.m. ET / 9 a.m. PT Reserve your spot now! 👉 https://bit.ly/4dSiSe7 #MedicareAdvantage #Healthcare #Webinar #InflationReductionAct #StarRatings #RegulatoryUncertainty

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Since when did health insurance companies received thier “MD’s”? This is a long article but a fascinating read. We wonder why healthcare costs continue to escalate and premiums are unaffordable? Well, when you have insurance companies being able to add diagnosis’s and conditions to a members healthcare record which allows them to receive more money for treatment - oh and by the way these members don’t have these illnesses…rocket science not needed here! While this seems like its a “Medicare” problem - it’s happening everywhere. In your commercial and group health plan too. Providers trying to charge patients for negotiated discounts, millions of dollars in fake billings, pharmacy rebates being used to increase insurance company profits versus going back to the companies footing these bills or the patients using the drugs. Insurance companies and the organizations that own physician groups and hospitals have figured out how to game the system to increase profits - not deliver better health outcomes. I do believe that there are a lot of great professionals in the medical field that honestly want to improve the lives of people that they treat - they unfortunately now mostly work for companies that don’t really care much about that.

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With the struggles that many health plans are facing in Medicare Advantage, understanding care management and where the best place to focus resources and hit the gas is of utmost importance. With that in mind, I'll be brushing up on this oldie but goodie from the SOA in the early 2000s and will be sharing my thoughts as I go. https://lnkd.in/eZWnVS8q #Medicare #CareManagement #Wakely

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