Patient Protection and Affordable Care Act; Adoption of the Methodology for the HHS-Operated Permanent Risk Adjustment Program for the 2018 Benefit Year Final Rule. Final rule

This final rule adopts the HHS-operated risk adjustment methodology for the 2018 benefit year. In February 2018, a district court vacated the use of statewide average premium in the HHS-operated risk adjustment methodology for the 2014 through 2018 benefit years. Following review of all submitted comments to the proposed rule, HHS is adopting for the 2018 benefit year an HHS-operated risk adjustment methodology that utilizes the statewide average premium and is operated in a budget-neutral manner, as established in the final rules published in the March 23, 2012 and the December 22, 2016 editions of the Federal Register.

Why a national high-risk insurance pool is not a workable alternative to the marketplace

The Pre-Existing Condition Insurance Plan (PCIP) was a national high-risk pool established under the Affordable Care Act (ACA) to provide coverage for individuals with preexisting conditions who had been uninsured for at least six months. It was intended to be a temporary program: PCIPs opened in 2010 and closed in April 2014. At that point, those with preexisting conditions could shop for health insurance in the marketplaces, where plans are prevented from using applicants' health status to deny coverage or charge more. This issue brief draws on the PCIP experience to outline why national high-risk pools, which continue to be proposed as policy alternatives to ACA coverage expansions, are expensive to enrollees as well as their administrators and ultimately unsustainable. The key lesson--and the principle on which the ACA is built--is that insurance works best when risk is evenly spread across a broad population.

Pre-Existing Condition Insurance Plan program. Interim final rule with comment period

This interim final rule with comment period sets the payment rates for covered services furnished to individuals enrolled in the Pre-Existing Condition Insurance Plan (PCIP) program administered directly by HHS beginning with covered services furnished on June 15, 2013. This interim final rule also prohibits facilities and providers who, with respect to dates of service beginning on June 15, 2013, accept payment for most covered services furnished to an enrollee in the federally-administered PCIP from charging the enrollee an amount greater than the enrollee's out-of-pocket cost for the covered service as calculated by the plan. The PCIP program was established under Section 1101 of Title I of the Patient Protection and Affordable Care Act (Affordable Care Act).

The Affordable Care Act's pre-existing condition insurance plan: enrollment, costs, and lessons for reform

The Pre-Existing Condition Insurance Plan (PCIP) is the temporary, federal high-risk pool created under the Affordable Care Act to provide coverage to uninsured individuals with preexisting conditions until 2014, when exchange coverage becomes avail­able to them. Nearly 78,000 people have enrolled since the program was implemented two years ago. This issue brief compares the PCIP with state-based high-risk pools that existed prior to the Affordable Care Act and considers programmatic differences that may have resulted in lower-than-anticipated enrollment and higher-than-anticipated costs for the PCIP. PCIP coverage, like state high-risk pool coverage, likely remains unaffordable to most lower-income individuals with preexisting conditions, but provides much needed access to care for those able to afford it. Operational costs of these programs are also quite high, making them less than optimal as a means of broader coverage expansion.

Risk adjustment under the Affordable Care Act: a guide for federal and state regulators

To achieve the aims of the Affordable Care Act, state and federal regulators must construct an effective system of risk adjustment, one that protects health insurers that attract a disproportionate share of patients with poor health risks. This brief, which summarizes a Commonwealth Fund–supported conference of leading risk adjustment experts, explores the challenges regulators will face, considers the consequences of the law's risk adjustment provisions, and analyzes the merits of different risk adjustment strategies. Among other recommendations, the brief suggests that regulators use diagnostic rather than only demographic risk measures, that they allow states some but limited flexibility to tailor risk adjustment methods to local circumstances, and that they phase in the use of risk transfer payments to give insurers more time to predict and understand the full effects of risk adjustment.

High-risk pools for the sick and uninsured under health reform: too little and thus too late

Democrats and Republicans have turned to the concept of "high-risk pools" to provide health care for those Americans who face the dual challenge of uninsurance and serious health difficulties. Under the Patient Protection and Affordable Care Act (PPACA), these "high-risk" individuals will receive extensive help and regulatory protections, in concert with a new system of health insurance exchanges. However, these federal provisions do not become operational until 2014. As an interim measure, PPACA provides $5 billion for temporary, federally funded high-risk pools, now known as the Pre-Existing Condition Insurance Plan (PCIP). This analysis explores the adequacy of such funding. Using 2005/06 data from the National Health and Nutrition Examination Survey (NHANES), we find that approximately 4 million uninsured Americans have been diagnosed with emphysema, diabetes, stroke, cancer, congestive heart failure, angina, or a heart attack. To provide adequate health care for uninsured individuals with chronic diseases, the federal PCIP appropriations would need to be many times higher than either Democrats or Republicans have proposed.

Pre-Existing Condition Insurance Plans created by the Affordable Care Act of 2010

The Patient Protection and Affordable Care Act includes a provision for the establishment of a temporary high-risk pool, also called the Pre-Existing Condition Insurance Plan (PCIP), to quickly make health insurance available to uninsured individuals with preexisting conditions, many of whom previously had been denied coverage. Twenty-seven states elected to administer the PCIPs for their citizens, while the remaining states and the District of Columbia chose to let their PCIPs be federally administered. This issue brief examines eligibility, benefits, premiums, cost-sharing, and oversight of the PCIP programs, as well as variation of the plans from state to state. The PCIPs will run through December 31, 2013, at which time participants will be transitioned to exchange coverage.

Pre-existing condition insurance plan program. Interim final rule with comment period

Section 1101 of Title I of the Patient Protection and Affordable Care Act of 2010 (Affordable Care Act) requires that the Secretary establish, either directly or through contracts with States or nonprofit private entities, a temporary high risk health insurance pool program to provide affordable health insurance coverage to uninsured individuals with pre-existing conditions. This program will continue until January 1, 2014, when Exchanges established under sections 1311 and 1321 of the Affordable Care Act will be available for individuals to obtain health insurance coverage. This interim final rule implements requirements in section 1101 of the Affordable Care Act. Key issues addressed in this interim final rule include administration of the program, eligibility and enrollment, benefits, premiums, funding, and appeals and oversight rules.

The long shadow of the past: risk pooling and the political development of health care reform in the States

Why do the states seem to be pursuing different types of policy innovation in their health reform? Why so some seem to follow a "solidarity principle," while others seem guided by a commitment to "actuarial fairness"? Our analysis highlights the reciprocal influence of stakeholder mobilization and public policy over time. We find that early policy choices about how to achieve cost containment led the states down different paths of reform. In the 1970s and 1980s, states that featured oligopolistic or near-monopolistic markets for private insurance (usually dominated by Blue Cross) and strong urban-academic hospitals tended to adopt regulatory strategies for cost containment that led to broader forms of pooling and financing the costs of health risks--which subsequently positioned them to pursue major, solidaristic reform on favorable terms. On the other hand, states with competitive markets for private insurance and weak, decentralized hospitals tended to adopt market-based strategies for cost containment that led to the hypersegmentation of risk and the uneven financing of costs--thereby encouraging the proliferation of incremental policies that reinforce the principle of actuarial fairness. We illustrate our analysis with a brief comparison of Massachusetts and California, and we conclude with some thoughts on what our findings imply for the federal role in catalyzing health reform.

Reassessing insurers' access to genetic information: genetic privacy, ignorance, and injustice

Many countries have imposed strict regulations on the genetic information to which insurers have access. Commentators have warned against the emerging body of legislation for different reasons. This paper demonstrates that, when confronted with the argument that genetic information should be available to insurers for health insurance underwriting purposes, one should avoid appeals to rights of genetic privacy and genetic ignorance. The principle of equality of opportunity may nevertheless warrant restrictions. A choice-based account of this principle implies that it is unfair to hold people responsible for the consequences of the genetic lottery, since we have no choice in selecting our genotype or the expression of it. However appealing, this view does not take us all the way to an adequate justification of inaccessibility of genetic information. A contractarian account, suggesting that health is a condition of opportunity and that healthcare is an essential good, seems more promising. I conclude that if or when predictive medical tests (such as genetic tests) are developed with significant actuarial value, individuals have less reason to accept as fair institutions that limit access to healthcare on the grounds of risk status. Given the assumption that a division of risk pools in accordance with a rough estimate of people's level of (genetic) risk will occur, fairness and justice favour universal health insurance based on solidarity.

Insurance discrimination on the basis of health status: an overview of discrimination practices, federal law, and federal reform options

This is an important time to focus on the question of insurance discrimination based on health status. The nation once again is poised to embark on a major health care reform debate. Even as the number of uninsured stands at some 45 million persons, millions more may be poised to lose coverage during the worst economic downturn in generations. In addition, a large number of persons may be seriously under-insured, with coverage falling significantly below the cost of necessary health care. In recent years, the proportion of insured persons who are underinsured has grown by 60% since 2003, reaching an estimated 25 million persons in 2007. Health care costs experienced by insured persons now account for more than 75% of all personal bankruptcies related to medical care. Underlying these figures is a national approach to health care financing for the non-elderly that effectively increases the odds that those who are in poor health status will be uninsured or underinsured.

Health insurance exchanges: legal issues

This “Legal Solutions in Health Reform” paper identifies and analyzes the legal issues raised by health insurance exchanges. Like all Legal Solutions papers, it does not purport to provide a concrete proposal as to how health insurance exchanges should be organized or even whether they should play a role in health care reform. Rather, it attempts simply to describe the legal issues that health insurance exchanges raise, and to propose alternative solutions to legal problems where useful. More specifically, it analyzes and offers alternative solutions to the legal problems raised by proposals to establish insurance exchanges by the federal government, by state governments, and by private entities or associations. Because the focus of this project and paper is on legal issues, discussion of policy and design issues is attenuated. Nevertheless, some attention to policy issues is unavoidable because law is the realization of policy.

Grants to states for operation of qualified high risk pools. Final rule

This rule finalizes the interim final rule with comment period that was published on July 27, 2007, regarding extended funding for seed and operational grants for State High Risk Pools under the Public Health Service Act.

High risk pools. Interim final rule with comment period. Interim final rule with comment period

This interim final rule with comment period will amend our regulations regarding grants to States for operation of qualified high risk pools to conform to provisions of the Deficit Reduction Act of 2005 and the State High Risk Pool Funding Extension Act of 2006. Those provisions extended funding for seed and operational grants for State High Risk Pools and amended section 2745 of the Public Health Service Act.

Risk pooling and regulation: policy and reality in today's individual health insurance market

Analysis of new data on the relationship between and premiums and coverage in the individual insurance market and health risk shows that actual premiums paid for individual insurance are much less than proportional to risk, and risk levels have a small effect on obtaining coverage. States limiting risk rating in individual insurance display lower premiums for high risks than other states, but such rate regulation leads to an increase in the total number of uninsured people. The effect on risk pooling is small because of the large amount of risk pooling in unregulated individual insurance.

Association Health Plans: What’s All The Fuss About?

Policymakers have tried to address the problem of the uninsured and to help small businesses with rising premiums by encouraging associations to offer coverage. Although supporters and opponents have made claims about the potential impact of this strategy, the association market has not been studied in depth. Examining current standards might explain why proponents seek changes. This paper discusses states' approaches to regulating health insurance offered by associations, including "self-insurance," as well as existing state exemptions from state insurance laws that otherwise would apply to coverage sold to small businesses, self-employed people, and individual purchasers. We also examine market problems such as insolvency and fraud.

North Carolina high-risk insurance pools

Imagine this: You are a 58-year-old man. You have worked all your life, paid taxes, and helped support your family. Two years ago you had a mild heart attack. Your wife has diabetes and high blood pressure. Luckily, you had health insurance through your job that helped you pay for the hospitalization, doctor's visits, and necessary medications for you and your wife. With a new diet, exercise, and the medications, you both are doing well managing your health problems. A little over a year ago, you lost your insurance when your company downsized. You found another job, but your current employer doesn't offer insurance. Your wife also works, but she works for a small employer that does not offer coverage. So, you pay approximately dollar 600/month for continuation coverage (COBRA) for your wife and yourself through your former employer. Last month, you found out your COBRA coverage is about to end. You want to continue to buy insurance coverage, but you were told that purchasing a comprehensive policy with a dollar 1,000 deductible (70% coinsurance) that covers your needed medications would cost more than dollar 4,000/month for your wife and yourself.

Leveling the play field: providing equal access to health insurance to all District of Columbia residents and workers

A unique law has been proposed that aims to level the playing field for individuals who work for small employers, are self-employed, and are unemployed, in the District of Columbia. The proposal would create one large group made up of all persons who live, work, or go to school in the District of Columbia, thus providing these individuals with the opportunity to be insured on the same terms and conditions as those who work for the government or for large employers.

The nongroup market as one element of a broader coverage-expansion strategy

Effective health insurance provides financial protection and access to services that maintain and improve health. Such coverage is difficult to obtain in the nongroup market, however, because of a lack of sponsorship, the nature of coverage available, adverse selection, and high administrative costs. However, certain interventions could make this market an effective avenue for expanding coverage to moderate- to high-income persons who lack access to employer-based coverage. In "less regulated" markets, we suggest broader, deeper funding of high-risk pools and standardization of benefits, preexisting condition exclusions, and waiting periods. In "more regulated" markets, a broadly funded reinsurance mechanism could moderate premiums.

Predicting response to regulatory change in the small group health insurance market: the case of association health plans and HealthMarts

Lack of health insurance continues to be a concern for many people, even among those who are employed, and employees of small firms are much less likely to be insured than employees of larger firms. For several years, the U.S. Congress has considered legislation that would establish two new vehicles for offering health insurance coverage to small employers: association health plans (AHPs) and HealthMarts. In this paper, we present a model for estimating the impact the new entities would have on coverage and premiums in the small group health insurance market. The model produces a range of estimates based on assumptions, among others, about demand for insurance among small firms and their willingness to switch to less expensive, less generous benefit plans. We estimate that approximately 4.6 million people would obtain coverage through AHPs and HealthMarts, but fewer than half a million of them would be newly insured (based on 1999 population figures). Premiums would increase slightly for firms that continued to purchase coverage in the traditional market.

Effects of "second generation" small group health insurance market reforms, 1993 to 1997

In the mid-1990s, several state legislatures enacted a "second generation" of small group health insurance reforms that required guaranteed issue of all products and prohibited the use of health as a rating factor. We use data from two large employer surveys to compare the behavior of small business in nine states that adopted these reforms between 1993 and 1997 to the behavior of small business in 11 states and the District of Columbia, where neither of these small group health insurance market reforms existed prior to 1997 (N = 8,465 in 1993; N = 12,219 in 1997). Our analyses focus on several outcomes: health insurance offer and enrollment rates in any employer plan, and in an HMO plan; turnover in offer decisions; and premiums, variability in premiums, and the rate of change in premiums. Overall, we find no effect of small group reform on any of the outcomes; the sign of the effect is not consistent across reform states, the estimates rarely attain statistical significance, and they show no consistent pattern across the outcomes within each state. Therefore, predictions of the harm these regulations might cause to the market have not come to pass. On the other hand, proponents' hopes for a solution to low coverage rates among small businesses have not materialized either.

HealthMarts, HIPCs (health insurance purchasing cooperatives), MEWAs (multiple employee welfare arrangements), and AHPs (association health plans): a guide for the perplexed

This paper considers how pending proposals to authorize new forms of group purchasing arrangements for health insurance would fit and function within the existing, highly complex market and regulatory landscape and whether these proposals are likely to meet their stated objectives and avoid unintended consequences. Cost savings are more likely to result from increased risk segmentation than through true market efficiencies. Thus, these proposals could erode previous market reforms whose goal is increased risk pooling. On the other hand, these proposals contain important enhancements, clarifications, and simplification of state and federal regulatory oversight of group purchasing vehicles. Also, they address some of the problems that have hampered the performance of purchasing cooperatives. On balance, although these proposals should receive cautious and careful consideration, they are not likely to produce a significant overall reduction in premiums or increase in coverage.

Health reform and employee health benefits programs

The impact of health reform on employee health benefits programs could be dramatic. Depending on the health reform program adopted, employers could face significant new regulatory and economic burdens in operating employee health benefits programs or could find themselves greatly relieved of such burdens. President Clinton's proposal, in particular, would dramatically alter today's practices. This article focuses on how the Clinton proposal would change employee health benefits programs. Although President Clinton has indicated a willingness to compromise, his legislation may prove to be a house of cards, with all provisions interdependent. Employers should study all pending proposals carefully and weigh in on the debate so as to ensure that lawmakers are fully educated before making potentially irreversible decisions.

Mandatory pooling as a supplement to risk-adjusted capitation payments in a competitive health insurance market

Risk-adjusted capitation payments (RACPs) to competing health insurers are an essential element of market-oriented health care reforms in many countries. RACPs based on demographic variables only are insufficient, because they leave ample room for cream skimming. However, the implementation of improved RACPs does not appear to be straightforward. A solution might be to supplement imperfect RACPs with a form of mandatory pooling that reduces the incentives for cream skimming. In a previous paper it was concluded that high-risk pooling (HRP), is a promising supplement to RACPs. The purpose of this paper is to compare HRP with two other main variants of mandatory pooling. These variants are called excess-of-loss (EOL) and proportional pooling (PP). Each variant includes ex post compensations to insurers for some members which depend to various degrees on actually incurred costs. Therefore, these pooling variants reduce the incentives for cream skimming which are inherent in imperfect RACPs, but they also reduce the incentives for efficiency and cost containment. As a rough measure of the latter incentives we use the percentage of total costs for which an insurer is at risk. This paper analyzes which of the three main pooling variants yields the greatest reduction of incentives for cream skimming given such a percentage. The results show that HRP is the most effective of the three pooling variants.