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November 15, 2012 at 08:54 AM
State insurance regulators are continuing to tinker with the rules health insurers will have to follow when complying with the new federal minimum medical loss ratio (MLR) rules.
The MLR subgroup — a unit of a unit of a task force at the National Association of Insurance Commissioners — has been looking at questions about how to reconcile the MLR rules with other new rules created by the Patient Protection and Affordable Care Act of 2010 (PPACA).
The subgroup has, for example, been talking about how health insurance MLR calculations will fit with PPACA health insurance risk-management mechanisms.
The subgroup has posted documents relating to the relationship between risk-management mechanisms and minimum MLR rules on the Health Actuarial Task Force section of the NAIC’s website.
PPACA
The PPACA MLR provisions already require non-grandfathered health insurers to spend 85 percent of large group revenue and 80 percent of individual and small group revenue on health care and quality improvement efforts.
Insurers that miss the mark must send customers rebates.
Starting late in 2013, health insurers are supposed to start selling individual coverage on a guaranteed-issue, mostly community-rated basis. Insurers will be able to take an applicant’s age into account when pricing coverage for that applicant but not the applicant’s state of health.
PPACA drafters created three risk-management mechanisms to try to help health insurers cope with the dramatic changes in underwriting rules:
- A temporary “risk corridor” program that will be run by the U.S. Department of Health and Human Services (HHS) is supposed to move cash from plans with medical expenses that are much lower than expected to plans with medical expenses that are much higher than expected.
- A temporary reinsurance program to be run either by HHS or state regulators is supposed to collect payments from the insurers in a state’s market and use the cash collected to support insurers that end up covering a high number of enrollees with high medical costs.
- A permanent risk-adjustment program to be run either by HHS or state regulators is supposed to use specific enrollee health information to shift cash from plans with unusually low-risk enrollees to plans with unusually high-risk programs.
The MLR subgroup
The MLR subgroup has been considering MLR/risk-management questions such as, “Should the reporting of MLR rebate calculations for 2014-2016 be modified to allow reflection of reinsurance, risk corridor payments and risk adjustment payments and credits?”
The subgroup also has been responding to a related question about whether “risk-adjustment payments (to high risk plans) and charges (from low risk plans)” should be reflected in MLR calculations.
