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Private Insurance: What State

Advocates Need to Know

Cheryl Fish-ParchamFamilies USA

January 25, 2007

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Insurance problems Not affordable:

Older or sicker people Young people Some small businesses

Not available to people in poor health Not adequate Employers are not covering their workers

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Problem: AffordabilityExample: DC Blue Cross/Blue Shield premium prices

for most comprehensive plans

$0

$200

$400

$600

$800

$1,000

$1,200

$1,400

Age 55 Age 22

healthynot healthy

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Affordability Tool: Rate Regulation How much insurers can vary premium

prices? Community rating: No price variation (NY, VT) Adjusted community rating: No variation based

on health (ME, MD, MA, NH, NJ, OR, WA). May limit total price variation (e.g., 3:1).

Rate Bands: Insurers identify their “index rate” and states limits how much more or less they can charge based on each factor (eg, +/-25% for each of age, health, industry)

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Rate regulation can also: Limit insurers’ administrative expenses,

surplus, and profits Medical loss ratios: Proportion of premium

dollars used to pay medical claims Eg, New Jersey requires at least a 75% loss ratio

Limit a non-profit’s surplus (what it retains over and above required reserves). Require excess resources to benefit the community.

Eg, Pennsylvania uses CareFirst surplus to fund coverage for low-income adults

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Questions to ask your state about rate regulation What factors can insurers use in setting

premiums for individuals? For small groups? Does the state limit premium variation? How does the state review proposed rates? Do insurers issue refunds if premiums are

unnecessarily high? What are nonprofit insurers surpluses? What must

nonprofit insurers do in exchange for their tax exemptions?

( See “Understanding How Health Insurance Premiums are Regulated,” www.familiesusa.org)

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Problem: UninsurableLA Times reports people are turned down for

insurance because they take medicines and based on profession:

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Availability Tool: Guaranteed Issue Require all health insurers to sell policies

to all, regardless of their health States that do this: MA, ME, NJ, NY, VT

Require some insurers, such as nonprofits, to sell to all regardless of their health CA, DC (but law is ending), MI, NC, OH, PA, VA

Source: Georgetown University Health Policy Institute, 2004.

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Availability Tool: High Risk Pools “Uninsurable” people can purchase

insurance through a state-established nonprofit association.

Premiums are capped. The risk pool is subsidized, often through

an assessment on insurers. In some states, premiums are further

subsidized for low-income enrollees.

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High Risk Pools: What to advocate33 states have high risk pools (but 2 are

quite limited). Advocate: Insurers, agents must tell people about

them Short or no waiting period for coverage of

preexisting conditions Premium caps no more than 125% of

standard rates Additional income-based subsidies

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High Risk Pools: More things to advocate Adequate funding, federal grants Decent benefits High coverage limits

(See issue brief: High Risk Health Insurance Pools, www.familiesusa.org)

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Availability and Affordability Tool: Reinsurance State or assessment on insurers subsidizes

highest cost claims Can make insurers willing to sell to high-

risk people and bring down cost of premiums

(On www.familiesusa.org, go to “2006 conference call series” for a recording of November call on reinsurance.)

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Problem: Inadequate coverage

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Adequacy tools Mandated benefits Standardized, comparable plans (e.g., NJ) Limit cost sharing Discourage high-deductible plans and

HSAs, or if they exist, make sure consumers have reasonably priced low-deductible alternatives

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Problem: Employer won’t offer insurance

Firms Offering Health Insurance

Under 200 workers

Over 200 workers

0%

20%

40%

60%

80%

100%

120%

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Employer coverage tool: pay or play Employer must pay an assessment to a

state fund; however, that amount is reduced or eliminated if the employer pays for employee health care.

VT and MA have enacted small assessments.

(See “Ideas That Work: Expanding Health Coverage for Workers,” on www.familiesusa.org)

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ERISA Cases Can’t force an employer to buy health insurance,

but true pay or play laws may be allowed. Maryland Fair Share case lost, but may be

appealed. Issues: Whether it singled out Walmart Whether it required a national employer to change its

accounting system and employee benefits for one state.

( See “Making History: Maryland’s Fair Share Law,” on www.familiesusa.org; Patricia Butler, “ERISA Implications for State Health Care Initiatives,” on www.nashp.org)

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Other tools Pooled purchasing – generally doesn’t

bring down costs but helps make plans available to small businesses

State-offered plan (eg, Medicaid buy-in) “Connector” sells certified plans to

individuals as group coverage. (Eg, Massachusetts)

Small business tax credits