Health Plan Economics Masterclass

Foundations: The Economics Behind Coverage
This opening session frames the core economic concepts that shape health plan decision-making across commercial, Medicare, and Medicaid markets. Faculty will introduce how premium dollars, rate dollars, risk, trend, reserves, and launch timing influence plan strategy and financial sustainability.

The session will close with a faculty exchange on the key differences across lines of business: commercial plans price the risk, Medicare plans bid against the benchmark, and Medicaid plans receive the rate.

Commercial Deep Dive: From Actuarial Pressures to Pharmacy Strategy
This session examines how commercial market economics influence benefit design, employer and broker expectations, stop-loss considerations, and how new high-cost therapies are absorbed into future rates.

The discussion will connect actuarial pressures to pharmacy leadership decisions, including formulary tiering, prior authorization criteria, rebate strategy, and site-of-care management.  

Medicare Deep Dive: Bids, Benchmarks, Stars, and Part D Redesign
This session explores the economic drivers shaping Medicare Advantage and Medicare Part D, including MA bids, benchmarks, CMS rebates, Star Ratings economics, and the impact of Part D redesign under the Inflation Reduction Act.

Faculty will discuss how these dynamics influence MA-PD formulary decisions and how policy changes are affecting plan behavior in real time.  

Medicaid Deep Dive: Rate Setting, Risk, Rebates, and Managed Care Strategy
This session focuses on the Medicaid landscape, including capitation rate-setting, actuarial soundness, medical loss ratio floors, risk corridors, federal and supplemental rebates, and the relationship between state plan and managed care organization responsibilities.

Faculty will also discuss what is driving Medicaid pharmacy trend, mitigation strategies across fee-for-service and managed care environments, and future areas of Medicaid policy focus.  

Open Panel: Ask Us Anything: The Health Plan Economics Hot Seat
The program concludes with a moderated discussion featuring all faculty. This interactive panel will compare how commercial, Medicare, and Medicaid plans respond differently to economic pressures, policy changes, high-cost therapies, and evolving market expectations.

Participants will have the opportunity to ask cross-line-of-business questions and explore how lessons from one market segment may inform thinking in another.