2004 Hot Issues in Health Care Conference

1. 2004 Hot Issues in Health Care Conference Colorado’s Regulatory Environment An Introductory Overview Susan Gambrill Deputy Commissioner, Consumer Affairs November 12, 2004

2. Multiple Jurisdictions • Federal Government • Medicare • FEHBP • Single employer, self-funded plans • HCPF • Medicaid • Child Health Plan • DOI • Fully-insured policies issued in Colorado

3. Complex and Confusing • Different rules for different market segments • Underwriting • Rating • Benefit Mandates • Different carriers in different market segments • Different rules for different types of plans (HMO, indemnity, etc.)

4. Variety of Regulated Topics • Network Adequacy • Prompt Payment • Marketing practices/disclosures • Coverage options (Mandated benefits) • Rating requirements • Appeals processes • Renewability • Product specific (dental, LTC, etc)

5. Insurance Principles -Market Mismatch??? • Broad spreading of risk vs. voluntary market • Normal risk profile vs. adverse selection (guaranteed issue) • Unknown risk vs. anticipated costs (prevention, maternity, etc)

6. Cover Colorado • State’s high risk pool • Safety net for those uninsurable in individual market • Growing in numbers • Premiums at 150% of market • Various funding sources

7. Trends • Increasing costs/consumer cost sharing • Higher deductibles/limited benefits • Too good to be true “deals” • Greater chance of federal involvement • Healthy risks opting out of insured market

8. DOI Consumer Complaint Information • Handled over 6000 health complaints last fiscal year • Recovered over $7.5 million for consumers • 56% complaints re claim issues; 13% complaints re underwriting; 8% complaints re marketing; 23% complaints re policyholder services • Additional 50,000 telephone or e-mail inquiries

9. Division of Insurance • Metro (303) 894-7499 • Statewide (800) 930-3745 • Fax (303) 894-7455 • www.dora.state.co.us/insurance