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H OLDING P LANS A CCOUNTABLE IN H EALTH R EFORM J OSHUA D. G OLDBERG

H OLDING P LANS A CCOUNTABLE IN H EALTH R EFORM J OSHUA D. G OLDBERG National Association of Insurance Commissioners August 4, 2010 State Coverage Initiatives Summer Meeting Minneapolis, Minnesota. Reform Timeline. 2010. 2011. 2012. 2013. 2014. 2015. 2016. 2017.

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H OLDING P LANS A CCOUNTABLE IN H EALTH R EFORM J OSHUA D. G OLDBERG

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  1. HOLDING PLANS ACCOUNTABLE IN HEALTH REFORM JOSHUA D. GOLDBERG National Association of Insurance Commissioners August 4, 2010 State Coverage Initiatives Summer Meeting Minneapolis, Minnesota

  2. Reform Timeline 2010 2011 2012 2013 2014 2015 2016 2017 Temporary High Risk Pool Program Temporary Early Retiree Reinsurance Program Immediate Reforms: • No Lifetime Limits • Restricted Annual Limits • Restrictions on Rescission • First Dollar Coverage of Preventive Services • Extended Dependent Coverage • Internal/External Review • No Pre-Existing Conditions for Children • Disclosure of Justifications for Premium Increases Medical Loss Ratios with Rebates Exchanges Subsidies Individual/Employer Mandates Market Reforms • Guaranteed Issue • No Pre-Existing Condition Exclusions for Adults • Rating Rules • Essential Benefits Plans • No Annual Limits for Essential Benefits Co-Op Plans & Multistate Plans Risk Adjustment Individual Market Reinsurance Program & Risk Corridors 2010 2011 2013 2014 2015 2016 2017 2012

  3. Preemption Provisions of PPACA will potentially preempt state laws. Similar to HIPAA: Nothing in this title shall be construed to preempt any State law that does not prevent the application of the provisions of this title. PPACA §1321(d) Exceptions: Mandated benefits: States must cover cost of mandated benefits beyond essential benefits package. Grandfathered plans: States may not require grandfathered plans to be pooled with post-reform plans.

  4. Rate Review Federal review of “unreasonable” rate increases. No federal authority to deny rate increase. May recommend exclusion from state-run Exchange May exclude from federally-run Exchange $250 million in grants to states to support rate review.

  5. Medical Loss Ratios Clinical Care Costs + Health Quality Improvement Premiums - Taxes & Regulatory Fees 85% in large group market 80% in small group and individual markets HHS has authority to reduce to prevent individual market instability.

  6. Rating Rules Adjusted community rating No health status Limited age (3:1 max) Limited tobacco (3:1 max) Geography Single risk pool requirements Individual and small group markets Grandfathered plans excluded

  7. Small Group Variation ME MN WI PA IA OH NE WV MD VA KY MO KS TN SC AR GA MS LA Community Rating NH VT Adjusted Community Rating WA MT ND No Rating Structure MA NY OR RI SD ID MI CT WY Rating Band Variability: NJ DE IN IL NV 13:1 or less UT CO CA DC 13.1:1 – 19:1 NC 19.1:1 – 25:1 OK AZ NM AL 25.1:1 or greater HI TX FL *Note: Michigan HMOs and Blue Cross/Blue Shield are restricted to 3.12:1 maximum variation. All others may use 3.96 maximum variation AK

  8. ME VT NH MN NY WI MI PA IA OH NE IN IL WV MD VA MO KY KS NC TN SC AR GA AL MS LA FL Individual Market Rating WA MT ND No Rating Structure MA OR Community Rating ID SD RI CT WY Adjusted Community Rating NJ DE Rating Bands NV UT CO CA Hybrid Michigan Blue Cross/Blue Shield must use community rating. There is no rating structure for other carriers. DC OK AZ NM HI TX AK

  9. ME VT NH MN NY WI MI PA IA OH NE IN IL WV MD VA MO KY KS NC TN SC AR GA AL MS LA FL Reformed Rating Rules WA MT ND No Rating Structure MA OR Community Rating ID SD RI CT WY Adjusted Community Rating NJ DE Rating Bands NV UT CO CA Hybrid Michigan Blue Cross/Blue Shield must use community rating. There is no rating structure for other carriers. DC OK AZ NM HI TX AK

  10. Reporting Requirements All plans must report to Secretary, State Insurance Commissioner and the Public: Claims payment policies and practices Financial disclosures Data on enrollment and disenrollment Data on claims denials Data on rating practices Information on cost-sharing for out-of-network providers Information on enrollee and participant rights under PPACA Other information specified by the Secretary

  11. Transparency Disclosure of premium justifications Uniform definitions of insurance terms Uniform summary of benefits Coverage facts labels Exchanges Reporting requirements

  12. Complaints and Appeals Internal review Equivalent to DoL Regulations Required for rescissions External review Equivalent to NAIC Model Extended to self-insured plans Consumer Assistance Grants

  13. Enforcement Immediate Reforms Form review process States have not had opportunity to change laws Fallback enforcement may be tricky 2014 Reforms NAIC will develop models meeting federal minimum standards

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