The U.S. Department of Health and Human Services (HHS) is adding “administrative costs,” including distribution costs, to the list of factors a health insurer can consider when setting individual and small group rates under the new rules that are set to take effect Jan. 1, 2014.
HHS also is:
- Telling states with their own “risk pools” for residents with health problems to let the pool members shift to other plans, if that’s what the pool members want to do.
- Letting student health plan sponsors separate the risk pools for students from their risk pools for the general population.
- Promising to say something about expatriate plans later.
- Suggesting that it will try to give states ideas later about tools the states, and insurers, can use to keep people from waiting until they are seriously ill to buy health insurance.
- Indicating that it’s still working on guidance relating to the state rating method update schedule, state rating program reporting requirements, and the age rating curve it will apply in states that fail to either establish their own age curve or give HHS data that HHS can use to create age curves for those states.
HHS has addressed those topics in an advance version of a final rule implementing health insurance market rule and rate review provisions (CMS-9972-F) in the Patient Protection and Affordable Care Act of 2010 (PPACA).
HHS intends to publish the final rule in the Federal Register Feb. 27.
Most provisions in the final rule will take effect 60 days after the official publication date and start to apply to individual and small group health insurance in plan years beginning on or after Jan. 1, 2014.
PPACA opponents are still trying to repeal the law or block implementation of part or all of the law, and HHS or other agencies could move to postpone implementation.
If the law takes effect on schedule and works as drafters expect, it will create a new system of exchanges, or health insurance supermarkets, starting Oct. 1.
PPACA will require all carriers selling non-grandfathered coverage inside or outside the exchanges after Jan. 1, 2014, to sell the coverage on a mostly guaranteed-issue basis, without considering personal health information.
Any non-grandfathered individual or small group health insurer will have to sell producuts that the cost of a specified percentage of the actuarial value of a standardized “essential health benefits” (EHB) package.” The cheapest, “bronze level” plans must cover 58 percent to 62 percent of the actuarial value of the EHB. The most expensive, “platinum level” plans must cover 88 percent to 92 percent of the EHB’s actuarial value.
PPACA already requires health insurers to spend 80 percent of individual and small group premium revenue on health care and quality improvement efforts or else make up the difference by sending enrollees rebates.
Other PPACA provisions and HHS regulations based on those provisions already require health insurers to post public explanations of any rate increases that exceed 10 percent.
PPACA will let an insurer charge the oldest insureds up to 3 times as much as it charges the youngest insureds, and it will let insurers charge up to 50 percent extra for enrollees who use tobacco. A plan also may be able to use increases or decreases in premiums in connection with wellness programs. Outside of tobacco use penalty programs and other wellness programs, plans will not be able to consider an individual’s health status when setting rates, officials say.
Two temporary risk-adjustment programs and a permanent risk-adjustment program are supposed to use cash from insurers with unusually healthy enrollees to help support insurers with unusually sick enrollees.
HHS released a draft version of the new regulations in November and received about 500 comments.
From the perspective of insurers and producers in the commercial health insurance market, some of the most interesting provisions dealt with any flexibility insurers will have when setting coverage rates.