ME Health Care Reform
Content
Provided By Brandon Cohen
Health Care Reform
On March 23, 2010, President Obama signed into law a comprehensive health care reform bill, the Affordable Care Act (ACA). ACA includes numerous reforms aimed at improving the U.S. health care delivery system, controlling health care costs and expanding health coverage. ACA’s reforms have staggered effective dates; some provisions are effective now, while others take effect in 2014 and later. ACA is a federal law, which means that federal agencies, namely the Departments of Labor (DOL), Health and Human Services (HHS) and the Treasury, are primarily responsible for the law’s overall enforcement. However, ACA also creates significant responsibilities for state governments. A number of ACA’s key health care reforms will be carried out at the state level. This Norton Insurance and Financial Employment Law Summary provides a high-level overview of selected ACA reforms to be implemented by state governments and highlights the progress being made in Maine. HEALTH INSURANCE EXCHANGES ACA requires each state to have a health insurance exchange (Exchange) to provide a competitive marketplace where individuals and small businesses will be able to purchase affordable private health insurance coverage, effective Jan. 1, 2014. According to HHS, the Exchanges will make it easier for individuals and small businesses to compare health plan options, receive answers to health coverage questions, determine eligibility for tax credits for private insurance or public health programs and enroll in suitable health coverage. Individuals and small employers with up to 100 employees will be eligible to participate in the Exchanges. However, states may limit employers’ participation in the Exchanges to businesses with up to 50 employees until 2016. Beginning in 2017, states may allow businesses with more than 100 employees to participate in the Exchanges. Enrollment in the Exchanges is expected to begin on Oct. 1, 2013. States have three options with respect to their Exchanges. A state may: Establish its own state-based Exchange; Have HHS operate a federally facilitated Exchange (FFE) for its residents; or Partner with HHS so that some FFE Exchange functions can be performed by the state.
States that intend to pursue a state-based Exchange or a state partnership Exchange must submit a blueprint to HHS by Nov. 16, 2012. The blueprint must contain a declaration letter signed by the state’s governor and an application describing readiness to perform Exchange activities and functions. If a state does not move forward with its Exchange or select the partnership model, HHS will operate the FFE in the state and will also perform the Exchange-related functions of risk adjustment and reinsurance. In April 2012, Governor Paul LePage (R) sent a letter to HHS indicating that Maine will not implement a state-based Exchange. Although Maine took some initial steps toward creating its own Exchange, including receiving federal grants, Exchange legislation failed in the state legislature in both 2011 and 2012. Unless Maine reverses course, HHS will operate the FFE for Maine’s residents.
This guide is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. It is provided for general informational purposes only. It broadly summarizes state statutes and regulations generally applicable to private employers, but does not include references to other legal resources unless specifically noted. Readers should contact legal counsel for legal advice. © 2012 Zywave, Inc. All rights reserved. EEM 10/12
Health Care Reform
TEMPORARY HIGH-RISK INSURANCE POOL ACA requires the establishment of a temporary high-risk health insurance pool to provide affordable health insurance coverage to uninsured individuals with pre-existing conditions. ACA’s high-risk health insurance pool is called the Pre-Existing Condition Insurance Plan (PCIP). The PCIP will continue until Jan. 1, 2014, when individuals will be able to purchase health coverage through ACA’s health insurance exchanges. HHS administers the PCIP in some states, while other states have requested to run their own PCIP. Maine administers its own PCIP, which is run by Dirigo Health Agency. More information on Maine’s PCIP is available at: www.dirigohealth.maine.gov/Pages/pre_exist.html. INSURANCE RATE REVIEW To help hold insurance companies accountable for their proposed rate hikes, ACA required HHS to establish a process to review the reasonableness of certain premium increases. Effective Sept. 1, 2011, insurers seeking rate increases of 10 percent or more for nongrandfathered plans in the individual and small group markets must publicly disclose the proposed increases along with justification for the increases. Starting Sept. 1, 2012, the 10 percent threshold will be replaced with a state-specific threshold to reflect insurance and health care cost trends particular to each state. HHS will work with states to develop the applicable thresholds.
The proposed increases must be reviewed by either state or federal experts to determine whether they are reasonable. States with effective rate review systems will conduct their own reviews, but if a state does not have the resources or authority to conduct rate reviews, HHS will conduct them. According to HHS, Maine has an effective system for reviewing rate increases in both the individual and small group markets. The Maine Bureau of Insurance conducts rate reviews for these markets. MEDICAL LOSS RATIO RULES ACA established the medical loss ratio (MLR) rules to help control health care coverage costs and ensure that enrollees receive value for their premium dollars. The MLR rules became effective on Jan. 1, 2011. Under the MLR rules, health insurance issuers in the large group market must spend at least 85 percent of premiums on medical costs and health care quality improvement activities. Issuers in the small group and individual markets must spend at least 80 percent of premiums on those items. Issuers that do not meet the applicable MLR standard must provide rebates to consumers. Rebates must be paid by Aug. 1 of each year. The first round of rebates was due by Aug. 1, 2012. ACA allows states to request a temporary adjustment in the MLR ratio for up to three years to avoid disruptions to coverage in the individual market. Maine requested a temporary MLR adjustment. Based on this request, HHS adjusted the MLR standard in Maine’s individual health insurance market to 65 percent for 2011, 2012 and 2013, with the adjustment for 2013 conditioned on the submission of additional data to support the need for the continued adjustment. HEALTH INSURANCE REFORMS ACA requires sponsors of self-funded and insured group health plans to make changes to their plans’ design and administration over the next several years. For example, effective for plan years beginning on or after Sept. 23, 2010, ACA requires: Group health plans to extend dependent coverage up to age 26; and Non-grandfathered group health plans to follow minimum requirements for external review of claims appeals.
Dependent Coverage Requirements Although ACA creates federal standards, the health insurance market is primarily regulated at the state level. Some states may have laws that go beyond the federal minimums established by ACA. For
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Health Care Reform
example, some states extend dependent coverage beyond age 26. Maine law does not generally require insured health plans to maintain dependent coverage beyond the federal minimum age limit. External Review Requirements In addition, ACA requires insured plans to comply with their state’s external review process if it includes certain minimum consumer protections. If a state’s external review process does not include the required minimum consumer protections, health insurers in the state must comply with a federal process for conducting external reviews, effective Jan. 1, 2012. HHS concluded that the Maine external review process includes the minimum consumer protections. Thus, insured health plans in Maine must conduct external appeals in accordance with the state’s external review process.
Brandon Cohen bcohen@ nortonne.com 800-777-5244
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Health Care Reform
On March 23, 2010, President Obama signed into law a comprehensive health care reform bill, the Affordable Care Act (ACA). ACA includes numerous reforms aimed at improving the U.S. health care delivery system, controlling health care costs and expanding health coverage. ACA’s reforms have staggered effective dates; some provisions are effective now, while others take effect in 2014 and later. ACA is a federal law, which means that federal agencies, namely the Departments of Labor (DOL), Health and Human Services (HHS) and the Treasury, are primarily responsible for the law’s overall enforcement. However, ACA also creates significant responsibilities for state governments. A number of ACA’s key health care reforms will be carried out at the state level. This Norton Insurance and Financial Employment Law Summary provides a high-level overview of selected ACA reforms to be implemented by state governments and highlights the progress being made in Maine. HEALTH INSURANCE EXCHANGES ACA requires each state to have a health insurance exchange (Exchange) to provide a competitive marketplace where individuals and small businesses will be able to purchase affordable private health insurance coverage, effective Jan. 1, 2014. According to HHS, the Exchanges will make it easier for individuals and small businesses to compare health plan options, receive answers to health coverage questions, determine eligibility for tax credits for private insurance or public health programs and enroll in suitable health coverage. Individuals and small employers with up to 100 employees will be eligible to participate in the Exchanges. However, states may limit employers’ participation in the Exchanges to businesses with up to 50 employees until 2016. Beginning in 2017, states may allow businesses with more than 100 employees to participate in the Exchanges. Enrollment in the Exchanges is expected to begin on Oct. 1, 2013. States have three options with respect to their Exchanges. A state may: Establish its own state-based Exchange; Have HHS operate a federally facilitated Exchange (FFE) for its residents; or Partner with HHS so that some FFE Exchange functions can be performed by the state.
States that intend to pursue a state-based Exchange or a state partnership Exchange must submit a blueprint to HHS by Nov. 16, 2012. The blueprint must contain a declaration letter signed by the state’s governor and an application describing readiness to perform Exchange activities and functions. If a state does not move forward with its Exchange or select the partnership model, HHS will operate the FFE in the state and will also perform the Exchange-related functions of risk adjustment and reinsurance. In April 2012, Governor Paul LePage (R) sent a letter to HHS indicating that Maine will not implement a state-based Exchange. Although Maine took some initial steps toward creating its own Exchange, including receiving federal grants, Exchange legislation failed in the state legislature in both 2011 and 2012. Unless Maine reverses course, HHS will operate the FFE for Maine’s residents.
This guide is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. It is provided for general informational purposes only. It broadly summarizes state statutes and regulations generally applicable to private employers, but does not include references to other legal resources unless specifically noted. Readers should contact legal counsel for legal advice. © 2012 Zywave, Inc. All rights reserved. EEM 10/12
Health Care Reform
TEMPORARY HIGH-RISK INSURANCE POOL ACA requires the establishment of a temporary high-risk health insurance pool to provide affordable health insurance coverage to uninsured individuals with pre-existing conditions. ACA’s high-risk health insurance pool is called the Pre-Existing Condition Insurance Plan (PCIP). The PCIP will continue until Jan. 1, 2014, when individuals will be able to purchase health coverage through ACA’s health insurance exchanges. HHS administers the PCIP in some states, while other states have requested to run their own PCIP. Maine administers its own PCIP, which is run by Dirigo Health Agency. More information on Maine’s PCIP is available at: www.dirigohealth.maine.gov/Pages/pre_exist.html. INSURANCE RATE REVIEW To help hold insurance companies accountable for their proposed rate hikes, ACA required HHS to establish a process to review the reasonableness of certain premium increases. Effective Sept. 1, 2011, insurers seeking rate increases of 10 percent or more for nongrandfathered plans in the individual and small group markets must publicly disclose the proposed increases along with justification for the increases. Starting Sept. 1, 2012, the 10 percent threshold will be replaced with a state-specific threshold to reflect insurance and health care cost trends particular to each state. HHS will work with states to develop the applicable thresholds.
The proposed increases must be reviewed by either state or federal experts to determine whether they are reasonable. States with effective rate review systems will conduct their own reviews, but if a state does not have the resources or authority to conduct rate reviews, HHS will conduct them. According to HHS, Maine has an effective system for reviewing rate increases in both the individual and small group markets. The Maine Bureau of Insurance conducts rate reviews for these markets. MEDICAL LOSS RATIO RULES ACA established the medical loss ratio (MLR) rules to help control health care coverage costs and ensure that enrollees receive value for their premium dollars. The MLR rules became effective on Jan. 1, 2011. Under the MLR rules, health insurance issuers in the large group market must spend at least 85 percent of premiums on medical costs and health care quality improvement activities. Issuers in the small group and individual markets must spend at least 80 percent of premiums on those items. Issuers that do not meet the applicable MLR standard must provide rebates to consumers. Rebates must be paid by Aug. 1 of each year. The first round of rebates was due by Aug. 1, 2012. ACA allows states to request a temporary adjustment in the MLR ratio for up to three years to avoid disruptions to coverage in the individual market. Maine requested a temporary MLR adjustment. Based on this request, HHS adjusted the MLR standard in Maine’s individual health insurance market to 65 percent for 2011, 2012 and 2013, with the adjustment for 2013 conditioned on the submission of additional data to support the need for the continued adjustment. HEALTH INSURANCE REFORMS ACA requires sponsors of self-funded and insured group health plans to make changes to their plans’ design and administration over the next several years. For example, effective for plan years beginning on or after Sept. 23, 2010, ACA requires: Group health plans to extend dependent coverage up to age 26; and Non-grandfathered group health plans to follow minimum requirements for external review of claims appeals.
Dependent Coverage Requirements Although ACA creates federal standards, the health insurance market is primarily regulated at the state level. Some states may have laws that go beyond the federal minimums established by ACA. For
2
Health Care Reform
example, some states extend dependent coverage beyond age 26. Maine law does not generally require insured health plans to maintain dependent coverage beyond the federal minimum age limit. External Review Requirements In addition, ACA requires insured plans to comply with their state’s external review process if it includes certain minimum consumer protections. If a state’s external review process does not include the required minimum consumer protections, health insurers in the state must comply with a federal process for conducting external reviews, effective Jan. 1, 2012. HHS concluded that the Maine external review process includes the minimum consumer protections. Thus, insured health plans in Maine must conduct external appeals in accordance with the state’s external review process.
Brandon Cohen bcohen@ nortonne.com 800-777-5244
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