Insurance regulators are wrestling with questions about the definitions they should use when implementing the new Affordable Care Act minimum medical loss ratio rules.
Consumer representatives have told the Patient Protection and Affordable Care Act actuarial subgroup, an arm of the Accident and Health Working Group at the National Association of Insurance Commissioners, Kansas City, Mo., that regulators should be strict about keeping health insurers from putting costs that may not do much to help patients in the medical cost category.
Health insurance company executives say regulators should let insurers put a wide range of wellness, condition management and patient education expenses in the medical cost category.
ACA is the legislative package that includes PPACA and the Health Care and Education Reconciliation Act.
The Accident and Health Working Group is developing a response to a request for minimum MLR information recently issued by officials at the U.S. Department of Health and Human Services, the U.S. Labor Department and the U.S. Treasury Department.
A team of 17 NAIC consumer representatives says regulators should forbid insurers from putting activities related to “quality” in the medical cost category unless there is evidence that the activities improve care or coverage quality.
“For example,” the consumer reps write, “most consumers would not consider ‘utilization review’ nurses and other administrators whose job it is to review and often deny physician-recommended treatments to be providing medical care or, in many if not most cases, ‘improving quality’ of their health.”
Regulators should let insurers include the cost of helping physicians invest in information technology systems in the medical cost category, but many other health insurance IT costs have nothing to do with improving care or coverage quality, the consumer reps write.
One insurer reports having 34 condition management programs in place, but the National Committee for Quality Assurance, Washington, accredits only 5 types of condition management programs, the consumer reps note.
Molina Healthcare Inc., Long Beach, Calif., says regulators should let insurers classify many types of quality improvement costs, such as the cost of health risk assessment and assessment analysis programs, in the medical expense category.
Molina says the term “medical cost” also should include items such as the cost of screenings, immunizations and health education programs; nurse advice line expenses; maternity and neonatal risk assessment and education programs; disease management and case management programs; complex case management programs; recordkeeping quality control programs; care quality and complaint handling programs; provider credentialing programs; and monitoring and management of underuse and overuse of services.