Health System Reform Insight - May 5, 2011
Given the new direction for the nation's health system, the AMA has developed Health System Reform Insight to help you understand the Affordable Care Act and what it means to you and your patients.
Editor's note: This edition concludes a two-part series on issues that involve state insurance commissioners and the National Association of Insurance Commissioners—and the AMA's advocacy on those issues. View Part 1 of the series.
Even though the ACA is federal law, it includes numerous opportunities for state input and flexibility as it is implemented. While state officials in both the executive and legislative branches are very involved in implementing the ACA, state insurance commissioners have taken the lead on many key projects.
The National Association of Insurance Commissioners (NAIC) has been instrumental in facilitating policy discussions among insurance commissioners and drafting recommendations for use by both federal and state level policy-makers, and the AMA has been representing physician and patient interests before the NAIC. Following is a list of aspects of the ACA in which the NAIC has been involved, followed by AMA advocacy efforts on those fronts.
Consumer information subgroup
The ACA requires health insurers to provide consumers with understandable health benefit information, including standard definitions, clear coverage fact scenarios, explanations of coverage, a uniform health insurance enrollment form and other materials that ensure consumers understand their health care benefits.
Again, the ACA delegated the authority to draft recommended language on these issues to the NAIC. In response, the NAIC formed the Consumer Information Subgroup, consisting of representatives of consumers, insurers, regulators and providers. Notably, the AMA was the only provider representative on the subgroup. The AMA has advocated for accurate and patient-friendly materials throughout the process and chairs the Uniform Enrollment Subcommittee.
Health insurance exchanges
Last year the NAIC adopted the American Health Benefit Exchange Model Act to help states implement health insurance exchanges. The model act provides the basic elements that states must adopt in their exchanges to comply with the ACA, but it does not take a position on many of the key decision points.
The NAIC wants to provide states with flexibility on these issues, such as governance of the exchange, preventing adverse selection, the role of agents, and merging the individual and small group market exchanges. To help states with these issues, the NAIC is producing white papers that will provide states with options on implementation and help them think through how they want to proceed.
The AMA provided comments to the NAIC on the model act and has been commenting on the white papers on a regular basis. Recently the AMA has called for exchanges to include a physician finder search tool that allows patients to identify their physicians in the qualified health plans (QHPs) sold on the exchanges. The AMA also has called on the NAIC to recommend that states do not establish agent payment structures that would cause agents to favor outside-the-exchange plans rather than QHPs sold on the exchanges. This is important because if agents are encouraged to sell outside-the-exchange plans, that could lead to adverse selection in the exchanges.
The NAIC had a hearing on exchange issues at a recent meeting to help states work through some of these topics.
The ACA calls on the Health and Human Services (HHS) secretary, in conjunction with states, to develop a process for the annual review of unreasonable increases in health insurance premiums. The NAIC developed a sample form that all insurers would have to fill out if they filed an unreasonable rate increase.
The AMA commented several times to the NAIC about the form, successfully calling for transparency from health insurers. The HHS has reviewed the sample NAIC form and produced its own version for health insurers to use if their filing is termed "unreasonable." The AMA is reviewing HHS's proposed form and will comment as appropriate to both the NAIC and HHS.
Learn more about the AMA's state efforts on health system reform.
Comments are due on proposed rules covering the Centers for Medicare & Medicaid Services' accountable care organization program.