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Review of CMS Proposed 2018 Risk Adjustment Changes to CSR Plans (PDF)

"Wakely reviewed CMS' proposed 2018 risk adjustment changes to cost-sharing reduction (CSR) plans and modeled the impact of the changes based on collected 2016 data. [The] modeling with national data shows that relative risk will decrease around 10% for the 87% and 94% CSR plans while all other plans' relative risk will increase at varying levels to offset the changes to CSR plans."

Annual Wellness Visits and the Economics of Prevention: Insights from a Study of Medicare Enrollees (PDF)

14 pages. "[Annual Wellness Visits (AWVs)] are considerably underused, with 45 percent of Medicare beneficiaries not engaging with their AWVs.... [Fee-for-service] beneficiaries who were more engaged with their AWVs (had at least four AWVs from 2018 to 2023) had a lower annual trend in their total cost of care (TCOC) and considerably lower inpatient and emergency department spending.... [B]eneficiaries who received an AWV were associated with an average of $885 reduction in TCOC per beneficiary per year compared to years without an AWV."

Employer-Sponsored Health Benefits: Considering Self-Funding (PDF)

"Although fully insured plans provide simplicity and predictability, self-funding offers employers more flexibility and potential cost savings but with added risk and responsibility. This paper provides an overview of self-funding mechanics, risks, and planning considerations and sets the stage for future installments in a series that will dive into more advanced topics."

2025 Individual Market Risk Pool Considerations (PDF)

11 pages. "This whitepaper provides a preliminary view into how the individual market risk pool is shifting in 2025 following the Medicaid redetermination period in 2023-2024, sizable historical market growth, and other recent enrollment dynamics. Early results point to a notable increase in market risk for 2025, with demographic normalized relative risk rising over 8.3% and 8.0% when comparing 2023 and 2024 to 2025 for the January-April period. "

Summary of Draft CY 2025 Medicare Part D Redesign Program Instructions (PDF)

14 pages. "[CMS] released draft instructions on the CY2025 Part D Redesign. These draft instructions touch on many of the outstanding Part D benefit adjudication questions that the industry has been asking.... in addition to reinsurance, medical loss ratio, risk corridor, and Out-of-pocket cost (OOPC)/meaningful difference methodologies. Some guidance on Employer Group Waiver Plans (EGWPs) was also provided."

Impact of CSR De-Funding on Market Stability (PDF)

14 pages. "Colorado is requiring issuers to apply the CSR load to all metal levels instead of just the Silver plans.... New York is largely unaffected by these changes as the populations that would qualify for the CSR 87% and 94% plans are covered under the state's Basic Health Plan.... Oregon has proposed to allow all issuers to increase their on- and off-exchange Silver rates by the same 7.1% in the event that CSRs are de-funded.... States such as Vermont and Massachusetts have merged individual and small group markets. The impact of CSR de-funding may extend to the small group market in addition to the individual market."

Summary of Proposed Marketplace Integrity and Affordability Rule (PDF)

"HHS estimates that overall, the cumulative impact of the proposed rules could reduce enrollment by up to two million consumers.... [K]ey changes included in this proposed rule: [1] Changes for 2026 AV de minimis ... [2] Maximum out of pocket ... [3] Increased documentation requirements ... [4] Restriction on premium payment thresholds ... [5] Shortening open enrollment period ... [6] Auto-enrollment changes ... [7] Changes to essential health benefits (EHB)."

Impact of 2026 Federal Actuarial Value Calculator Updates (PDF)

"The new version is methodologically similar to prior AVC models after two years in a row of substantial data updates and methodological changes.... [I]nflation continues to drive high trend which will push a number of plans outside the upper ends of the de minimis ranges.... [T]he 2026 Maximum Out of Pocket limit (MOOP) saw its biggest increase ever to $10,150 from $9,200 in 20252. The offsetting results of these two changes will be explored [in this article]"

ICHRA/QSEHRA Considerations for Health Plans in 2025 (PDF)

"While still evolving, ICHRAs and QSEHRAs hold significant potential to impact the individual and small group market, warranting consideration by health plan actuaries involved in product development and pricing strategies."

Summary of Provisions of HHS' Proposed 2024 Notice of Benefit and Payment Parameters and Other Key Regs (PDF)

"The notice includes important proposed rules and parameters for the operation of the individual and small group health insurance markets in 2024 and beyond. This paper summarizes key provisions of the proposed notice, actuarial value calculator, and maximum out of pocket information recently released by HHS."