Implementing Commercial Insurance Market Aspects of Federal Health Reform: A State Perspective Christopher F. Koller Health Insurance Commissioner, State of RI April 30, 2010
Overview -What we are doing now -What we need to be thinking about for the future -States Challenges and Needs
Issues Now : High Risk Pool Grants ($5 billion – ) –For individuals who currently do not have coverage and have a pre- existing condition –Challenges: for states without high risk pool and for guarantee issue states Commercial Insurance Reforms (Plan years 6 mos. after enactment) –No lifetime limits; First-dollar coverage for preventive services –No rescissions; Appeals process –Dependent coverage up to 26 years of age –No Pre-existing Condition Exclusions for Children –MLR standards. Rate Oversight –Challenges: Reg promulgation process, communications, fit with existing statutes, implementation, other mkt impacts. Resources Grants for State Ombudsman National Web Portal
Key Reforms – 2014 Implementation Market Reforms: Guarantee Issue and no Pre-existing Condition Exclusions in all markets Rating Reforms limiting factors to age (3:1), geography, tobacco use and family composition 4 Coverage Tiers based on coverage categories and cost-sharing No annual limits State-Based Exchanges for Individual and Small Group markets that will provide standardized information on insurance choices and help consumers enroll in plans
State Action for Long Term Reforms: 1.(Stages of Grief) 2.Interagency Planning Groups 3.DC Monitoring (use of Membership Assocns) 4.Stakeholder Education and Communication 5.Exchange Planning: Goal setting Commercial and Medicaid interaction Operations 6.Eyes on the prize: Long term vision for local delivery systems (the cost issue) – payment reform, HIT, benefit design etc.
ME NY PA NH CT VT MA NJ VA NC SC GA FL WV KY AL MS MI WI MN IA HI AK KS NE ND SD MO IL IN TX MT ID NV UT WY CO NM AZ CA OR WA LA AR OK OH MD DE RI Community Rating 25.1:1 or greater Small Group Premium Variation DC Adjusted Community Rating Rating Band Variability: No Rating Structure19.1:1 – 25:1 13.1:1 – 19:1 13:1 or less *Note: Michigan HMOs and Blue Cross/Blue Shield are restricted to 3.12:1 maximum variation. All others may use 3.96 maximum variation TN
ME NY PA NH CT VT MA NJ VA NC SC GA FL WV KY TN AL MS MI WI MN IA HI AK KS NE ND SD MO IL IN TX MT ID NV UT WY CO NM AZ CA OR WA LA AR OK OH MD DE RI Rating Bands Hybrid Michigan Blue Cross/Blue Shield must use community rating. There is no rating structure for other carriers. Individual Market Rating Rules DC Adjusted Community Rating Community Rating No Rating Structure
State Needs and Challenges 1.Federalism made real: Coming into compliance from tremendously different starting points: technical and political issues. 2.Grandfathering of old plans (see briefing sheet). Enormous implications – good politics; bad policy. 3.New Federal Partnerships - HHS OCIIO. Competence is crucial. New roles 4.Communication and expectations with local stakeholders 5.Resources Resources Resources