Government Oversight of Private Insurance: What it Means for the Cost of Your Health Insurance
The plethora of health care laws passed in 2010 under the Affordable Care Act,include provisions for “rate setting” and monitoring of private sector insurance plans on a federal level. The ruling applies to all insurance plans which participate in any government funded health care program, including Medicare, Medicaid, and the soon-to-be-deployed regional insurance exchanges. This article explains how this differs from present rate monitoring and premium-setting and the ultimate impact on the consumer.
The Rules
Health & Human Services is charged with establishing a health insurance rate oversight committee, to assess the reasonableness of proposed health insurance rate increases starting in 2014. Since health insurance premiums have continued to grow at a rate in excess of inflation and increased 41% between 2003 and 2009, according to a Commonwealth Fund study , affordability is a concern. The federal PPACA law mandates health insurance as a means to providing national health care, so the viability of the national health care program depends on manageable health insurance premiums for the private sector.
Current State
Insurance premiums are determined based on each state’s rate authorization standards with the Insurance Commissioner, who is an elected official. Some states have a “use and file” policy which means the insurance company can decide to make plan changes, adjust the rates, and start implementing before the state approves them. Other states have a “file and preapproval” policy, which means you have to get the state office to approve of your math, the reasons for your plan increase first. The insurance company then has the opportunity to comment and either accept the commissioners regulations or withdraw the product. In the case of Principal Financial Group, when a previous Washington State Insurance Commissioner mandated that all individual medical plans provide maternity coverage and other provisions, they pulled their product from the state. In economic terms this is referred to as an unintended consequent of a regulatory action. The federal government does not have the authority to control state insurance premiums for the private sector. Medicare and Medicaid plans are of course, a different story as they are government plans.
Altered State
Through the process of gathering data, analyzing cost impacts, discerning patterns, and revealing information to health care purchasers, both individual and corporate, Health and Human Services, which oversees the Centers for Medicare and Medicaid, is charged with creating a more transparent process for what you actually end up paying for medical insurance. The intent is good, but there is no regulatory authority to enforce rate fairness by state and a regulation without enforcement can be problematic. Finally, the cost of the regulation will be borne by the private sector rate payers, which will add a nominal cost to individual premiums, spread over the entire population.
Economic Impact
I spoke briefly of unintended consequences above, but let me restate, if an additional regulation means more insurance companies will cease to offer insurance plans to the small group and individual markets, this may not be a good thing for consumers. Of course, the insurance industry is already seeing a reduction in the number of companies offering medical insurance and this trend has been going on since I was in the benefits business in the 80’s and 90’s. In short, private sector companies, both for-profit and not-for-profit will make market decisions based on where their strengths lie and act accordingly. And one could argue that as long as the companies which remain are of quality and offer good consumer products and services, this change is not untenable. The Netherlands and Switzerland both have private sector insurance programs financing their public health plans and only a hand full of companies provide the coverage, which seems to work fine. Also, they pay much less per-capita for health care than the United States does, but the healthpolicymaven has told you that before.
What it Means to the Health Insurance Premium Payer
OK, here is the “skinny” on this one, since the federal government Does Not have rate setting authority for insurance, which is controlled by each state’s elected insurance commissioner and those state administrators, this change will not have a direct impact on the rates you pay for medical insurance. What is more, since it is highly unlikely the government will be able to overturn ERISA or the McCarran Ferguson Act; don’t expect to see any rate relief. ERISA is the Employee Retirement Income Security Act which created the exemption for self-funded or self-insured plans, which most major employers have used to exempt themselves from many state and federal mandates. I do not see the government succeeding in overturning this act either. The McCarran Ferguson Act is a federal law which gives states the authority to regulate insurance. It should also be noted that insurance premiums taxes are a major source of funding for the states and they will never give up that revenue. Indirectly the fact the government is requiring the disclosure of the rate factors and will publish the information is a good thing for consumers. You will no longer have to be an insider in the insurance business, which you know I was for a couple of decades, to understand this process. In conclusion, will this make your insurance cheaper, no, because that depends on many complex factors that have to do with underfunding of government programs which the private sector has to support with cost transfers, market supply factors, and the degree to which primary health care is deployed in this country. Finally, people will still have to care enough to read about the provisions and many people don’t. The healthpolicymaven’s book, Unraveling U.S. Health Care should come out later this year and it is a guidebook to our health system, in lay person’s terms, which I am hoping will facilitate more outreach in this area.
Showing posts with label patient protection affordable care act. Show all posts
Showing posts with label patient protection affordable care act. Show all posts
Saturday, June 11, 2011
Friday, March 26, 2010
Insurance Changes from the Patient Protection and Affordable Care Act
How Insurance Companies, Employers, and Insureds will fare under the PPAC Act
Some of the legislators think the healthcare reform bill, signed by President Obama is a catastrophe, but from this angle it looks like a big win for the insurance industry. Though lots of things are missing from the bill, such as cost containment, this is the single biggest health care reform since Medicare was enacted in 1965. This article reviews how the current Patient Protection and Affordable Care Act impacts the insurance industry and its offerings.
Top 10 changes to the Insurance Industry with the PPACA law
1. Creation of the Federal Supplementary Medical Insurance Trust, funded through a panoply of new taxes to provide subsidies and expansion of health insurance programs, both government and private sector for the uninsured.
2. Medical insurance is now required for most U.S.A. residents (AKA lots of new customers!!!)
3. Removal of excessive waiting periods prior to commencement of insurance coverage
4. Removal of lifetime limits on benefits for medical insurance contracts
5. Insurers Required to post a Minimum Loss Ratio if participating in federal health plans like Medicare Advantage plans.
6. Extension of healthcare benefits for children to age 26
7. Closure of the prescription drug "donut hole" exclusion for Medicare recipients
8. Drug Rebates are provided for oral medicines that are re-formulations of existing drugs in an attempt to lower the cost of certain prescription medications
9. Establishment of health insurance exchanges and drug purchasing cooperatives
10. No changes in Cafeteria Plans until December 31, 2013
Pay or Play Provisions for Taxing Employers Who Don’t Offer Health Insurance
The Patient Protection and Affordable Care Act amended section 4980H of the Internal Revenue Code to provide tax assessment penalties for employers with fifty or more employees, who do not offer health insurance for their employees. The penalty will be between $2,000 and $3,000 per eligible employee, depending on the size of the employer. For some employers, it will still be worth it to avoid the expense of a medical insurance plan, which would cost over $5000 per employee and over $12,000 per family. According to the Kaiser Foundation’s Statehealthfacts.org, the cost for a single employee’s health insurance was $4,386 and the cost for a family was $12,298 in Washington State in 2008. But no matter how you look at this provision, it mandates more people buy medical insurance, which is a HUGE win for the insurance sector.
Funding of Insurance Mandates
The healthcare reform bill uses health insurance as a means to improve access to health care services for individuals and as such, provides federal tax credits to taxpayers to assist with the cost of the health insurance premiums.
For hospital systems, if more patients have access to insurance, there will be less uninsured services provided, which is a stabilizing factor for the health care industry. What remains to be seen, is how many of the 48,000,000 uninsured will be able to afford insurance for their families and will actually enroll, although the Obama Administration forecasts an additional 32,000,000 will obtain some form of health insurance, either government or private sector with this bill. To encourage participation, the law stipulates a tax penalty for those residents who don’t enroll in an insurance plan.
Medicaid Changes
Medicaid changes are a bright spot for healthcare providers as more people will be eligible for Medicaid, versus having no healthcare coverage now, which should reduce the stress on the under-funded population pass-through costs to private sector insurance participants. Granted Medicaid reimbursement is marginal, it is still better than no reimbursement, so this will increase viability of some hospitals, especially in the cities. The healthcare reform bill increases the allowance for the Federal Medical Assistance Percentage or FMAP for Medicaid Managed Care Plans.
Under fee-for-service reimbursement plans, family medicine, general internal medicine, and pediatric practitioners will also have increased reimbursement for primary care services.
Healthcare Purchasing Subsidy for Low Income Residents
For individuals who are not eligible for Medicaid or Medicare, but qualify for subsidized insurance purchasing, here is the subsidy range under the Patient Protection and Affordability Act, section 1402:
Household Income/ Insured’s Responsibility/ Subsidy
133% of FPL/ 3%/ 97%
Up to 400% of FPL/ 9.5%/ 91.5%
Individual Penalties for Residents who do not Obtain Health Insurance
Section 4980H of the Internal Revenue Code also provides that individuals who do not elect health insurance will be subject to a tax penalty, which would run between $325 and $695, depending on modified adjusted gross income levels. Many people may choose to pay the penalty rather than buy insurance because it is less expensive to pay the tax.
The combination of insurance tax subsidies, coerced employer contributions, and required individual insurance plan participation should help reduce some of the uninsured expenses which health systems experience, although it is difficult to forecast the level at this time. According to Hewitt Associates, when the COBRA subsidy kicked-in, enrollment increased by 20% for those beneficiaries. Also, individual participation in regional purchasing cooperatives is going to depend on how well those plans are communicated and ultimately, the cost of the plans.
Insurance Company Tax
Insurers will be assessed a premium tax to help pay for the provisions of health care under the Patient Protection and Affordability Act. Basically there is a formula that excludes certain activities from tax, has an offset, and has provisions for insurers that derive 80% or more of their revenue from low-income (re. Molina Healthcare), elderly (Medicare supplements), and disabled populations.
Health Insurance Luxury Plan Tax
High cost or "luxury" health plans will have to pay an excise tax up to 40%(yikes), based on an expected premium, with risk adjustments for that area. If the cost of your health insurance exceeds that threshold a tax will be assessed on the residual. The formula for determining which plans are high cost will be based on a per employee factor derived from Blue Cross/Blue Shield industry standards, which are age/risk/sex adjusted. Currently this threshold is $10,200 for an individual and $27,500 for a family, which is indexed for medical inflation. It is difficult to understand how this will help lower health costs, it seems to me it will just encourage employers to pass more costs onto their work force, who are already financially strapped. What are we doing, punishing the good guys who have great healthcare? Why not just mandate design elements with co-payments as opposed to only addressing the spend factor? This tax may force some plans to reduce some benefit levels to comply.
Medicare Changes
Medicare enrollees benefit by the following changes in reimbursements:
1. Closure of the prescription drug "donut hole" exclusion under Medicare Part D
Medicare enrollees who have used all of their prescription drug allowance will be reimbursed up to $250 to close this loophole. This reimbursement will be allowed once per year per enrollee for Medicare Part D drugs.
2. Changes in Medicare Advantage (HMO) payments
Qualifying counties will receive increased allowances, based on enrollment.
3. Quality rankings will impact Medicare Payments
Healthcare facilities with a quality ranking of four or higher will receive increased reimbursement from Medicare. Reimbursements will also depend on Medicare Advantage plan enrollment by county.
4. Transparency about plan expenses and administration costs
Under the Public Health Services Act, Medicare Advantage plans are required to have a claims loss ratio of 85% of premiums or the plan will have to pay a penalty to the government.
5. Physician Ownership Referral (Medical Home Provision)
This provision requires provider agreements to be signed for patients, designating a medical home status. This is part of Medicare’s efforts to improve primary care for Medicare patients by strengthening the primary care relationship.
Medicare Tax Increase
It should come as no surprise that there is an increase in the Medicare payroll tax, from 2.9% of total payroll to 3.80%, split evenly between the employee and the employer. Given the state of the Medicare fund, a bigger tax increase is warranted, and is probably on its way.
Other New Taxes
Medical Device Excise Tax
Medical devices, meaning cardiac pacemakers and such, will now be taxed at 2.9% of the purchase price. Orthopedic devices presumably are included in this category. Exceptions to the tax include; hearing aids, glasses, contacts, and over-the-counter devices purchased at the drug store. This tax will simply make these devices more expensive and will be passed directly through to the ratepayers and healthcare consumers. Also, in a nod to medical tourism, since this is an excise tax, even if you obtain healthcare outside of the United States, the device, if manufactured in this country, you will pay the tax.
Estate and Trust Tax
A tax equal to 3.8% will be levied on estates and trusts
Administrative Changes
Durable Medical Equipment Oversight
Durable Medical Equipment suppliers will be subject to an additional 90-day period of claim review, due to a high degree of suspected fraudulent activity in this supply sector. So, I guess this means they will be getting paid later.
Fraud Detection
The Commission of Medical Services in HHS is going to compare notes with the Internal Revenue Service as an enhanced Medicare fraud detection procedure.
Any semblance of privacy we had was lost with the post-911 anti-terrorist provisions, so lets just add this to the list of big brother invasiveness.
On a closing note, the Public Health Services Act imposes a slew of new taxes on corporations, individuals with investment income, and trusts. I just hope there is transparency in the spending of those funds and that is does actually go towards health care for those who need it.
This article was written by Roberta E. Winter, MHA, MPA, an independent healthcare consultant in the Pacific Northwest region of the United States, and may be reprinted with her permission.
Some of the legislators think the healthcare reform bill, signed by President Obama is a catastrophe, but from this angle it looks like a big win for the insurance industry. Though lots of things are missing from the bill, such as cost containment, this is the single biggest health care reform since Medicare was enacted in 1965. This article reviews how the current Patient Protection and Affordable Care Act impacts the insurance industry and its offerings.
Top 10 changes to the Insurance Industry with the PPACA law
1. Creation of the Federal Supplementary Medical Insurance Trust, funded through a panoply of new taxes to provide subsidies and expansion of health insurance programs, both government and private sector for the uninsured.
2. Medical insurance is now required for most U.S.A. residents (AKA lots of new customers!!!)
3. Removal of excessive waiting periods prior to commencement of insurance coverage
4. Removal of lifetime limits on benefits for medical insurance contracts
5. Insurers Required to post a Minimum Loss Ratio if participating in federal health plans like Medicare Advantage plans.
6. Extension of healthcare benefits for children to age 26
7. Closure of the prescription drug "donut hole" exclusion for Medicare recipients
8. Drug Rebates are provided for oral medicines that are re-formulations of existing drugs in an attempt to lower the cost of certain prescription medications
9. Establishment of health insurance exchanges and drug purchasing cooperatives
10. No changes in Cafeteria Plans until December 31, 2013
Pay or Play Provisions for Taxing Employers Who Don’t Offer Health Insurance
The Patient Protection and Affordable Care Act amended section 4980H of the Internal Revenue Code to provide tax assessment penalties for employers with fifty or more employees, who do not offer health insurance for their employees. The penalty will be between $2,000 and $3,000 per eligible employee, depending on the size of the employer. For some employers, it will still be worth it to avoid the expense of a medical insurance plan, which would cost over $5000 per employee and over $12,000 per family. According to the Kaiser Foundation’s Statehealthfacts.org, the cost for a single employee’s health insurance was $4,386 and the cost for a family was $12,298 in Washington State in 2008. But no matter how you look at this provision, it mandates more people buy medical insurance, which is a HUGE win for the insurance sector.
Funding of Insurance Mandates
The healthcare reform bill uses health insurance as a means to improve access to health care services for individuals and as such, provides federal tax credits to taxpayers to assist with the cost of the health insurance premiums.
For hospital systems, if more patients have access to insurance, there will be less uninsured services provided, which is a stabilizing factor for the health care industry. What remains to be seen, is how many of the 48,000,000 uninsured will be able to afford insurance for their families and will actually enroll, although the Obama Administration forecasts an additional 32,000,000 will obtain some form of health insurance, either government or private sector with this bill. To encourage participation, the law stipulates a tax penalty for those residents who don’t enroll in an insurance plan.
Medicaid Changes
Medicaid changes are a bright spot for healthcare providers as more people will be eligible for Medicaid, versus having no healthcare coverage now, which should reduce the stress on the under-funded population pass-through costs to private sector insurance participants. Granted Medicaid reimbursement is marginal, it is still better than no reimbursement, so this will increase viability of some hospitals, especially in the cities. The healthcare reform bill increases the allowance for the Federal Medical Assistance Percentage or FMAP for Medicaid Managed Care Plans.
Under fee-for-service reimbursement plans, family medicine, general internal medicine, and pediatric practitioners will also have increased reimbursement for primary care services.
Healthcare Purchasing Subsidy for Low Income Residents
For individuals who are not eligible for Medicaid or Medicare, but qualify for subsidized insurance purchasing, here is the subsidy range under the Patient Protection and Affordability Act, section 1402:
Household Income/ Insured’s Responsibility/ Subsidy
133% of FPL/ 3%/ 97%
Up to 400% of FPL/ 9.5%/ 91.5%
Individual Penalties for Residents who do not Obtain Health Insurance
Section 4980H of the Internal Revenue Code also provides that individuals who do not elect health insurance will be subject to a tax penalty, which would run between $325 and $695, depending on modified adjusted gross income levels. Many people may choose to pay the penalty rather than buy insurance because it is less expensive to pay the tax.
The combination of insurance tax subsidies, coerced employer contributions, and required individual insurance plan participation should help reduce some of the uninsured expenses which health systems experience, although it is difficult to forecast the level at this time. According to Hewitt Associates, when the COBRA subsidy kicked-in, enrollment increased by 20% for those beneficiaries. Also, individual participation in regional purchasing cooperatives is going to depend on how well those plans are communicated and ultimately, the cost of the plans.
Insurance Company Tax
Insurers will be assessed a premium tax to help pay for the provisions of health care under the Patient Protection and Affordability Act. Basically there is a formula that excludes certain activities from tax, has an offset, and has provisions for insurers that derive 80% or more of their revenue from low-income (re. Molina Healthcare), elderly (Medicare supplements), and disabled populations.
Health Insurance Luxury Plan Tax
High cost or "luxury" health plans will have to pay an excise tax up to 40%(yikes), based on an expected premium, with risk adjustments for that area. If the cost of your health insurance exceeds that threshold a tax will be assessed on the residual. The formula for determining which plans are high cost will be based on a per employee factor derived from Blue Cross/Blue Shield industry standards, which are age/risk/sex adjusted. Currently this threshold is $10,200 for an individual and $27,500 for a family, which is indexed for medical inflation. It is difficult to understand how this will help lower health costs, it seems to me it will just encourage employers to pass more costs onto their work force, who are already financially strapped. What are we doing, punishing the good guys who have great healthcare? Why not just mandate design elements with co-payments as opposed to only addressing the spend factor? This tax may force some plans to reduce some benefit levels to comply.
Medicare Changes
Medicare enrollees benefit by the following changes in reimbursements:
1. Closure of the prescription drug "donut hole" exclusion under Medicare Part D
Medicare enrollees who have used all of their prescription drug allowance will be reimbursed up to $250 to close this loophole. This reimbursement will be allowed once per year per enrollee for Medicare Part D drugs.
2. Changes in Medicare Advantage (HMO) payments
Qualifying counties will receive increased allowances, based on enrollment.
3. Quality rankings will impact Medicare Payments
Healthcare facilities with a quality ranking of four or higher will receive increased reimbursement from Medicare. Reimbursements will also depend on Medicare Advantage plan enrollment by county.
4. Transparency about plan expenses and administration costs
Under the Public Health Services Act, Medicare Advantage plans are required to have a claims loss ratio of 85% of premiums or the plan will have to pay a penalty to the government.
5. Physician Ownership Referral (Medical Home Provision)
This provision requires provider agreements to be signed for patients, designating a medical home status. This is part of Medicare’s efforts to improve primary care for Medicare patients by strengthening the primary care relationship.
Medicare Tax Increase
It should come as no surprise that there is an increase in the Medicare payroll tax, from 2.9% of total payroll to 3.80%, split evenly between the employee and the employer. Given the state of the Medicare fund, a bigger tax increase is warranted, and is probably on its way.
Other New Taxes
Medical Device Excise Tax
Medical devices, meaning cardiac pacemakers and such, will now be taxed at 2.9% of the purchase price. Orthopedic devices presumably are included in this category. Exceptions to the tax include; hearing aids, glasses, contacts, and over-the-counter devices purchased at the drug store. This tax will simply make these devices more expensive and will be passed directly through to the ratepayers and healthcare consumers. Also, in a nod to medical tourism, since this is an excise tax, even if you obtain healthcare outside of the United States, the device, if manufactured in this country, you will pay the tax.
Estate and Trust Tax
A tax equal to 3.8% will be levied on estates and trusts
Administrative Changes
Durable Medical Equipment Oversight
Durable Medical Equipment suppliers will be subject to an additional 90-day period of claim review, due to a high degree of suspected fraudulent activity in this supply sector. So, I guess this means they will be getting paid later.
Fraud Detection
The Commission of Medical Services in HHS is going to compare notes with the Internal Revenue Service as an enhanced Medicare fraud detection procedure.
Any semblance of privacy we had was lost with the post-911 anti-terrorist provisions, so lets just add this to the list of big brother invasiveness.
On a closing note, the Public Health Services Act imposes a slew of new taxes on corporations, individuals with investment income, and trusts. I just hope there is transparency in the spending of those funds and that is does actually go towards health care for those who need it.
This article was written by Roberta E. Winter, MHA, MPA, an independent healthcare consultant in the Pacific Northwest region of the United States, and may be reprinted with her permission.
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