2019 Individual Insurance Market - Hot Topics - HC4ME October 1, 2018 - Consumers ...
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2019 Individual Insurance Market –
Hot Topics
HC4ME
October 1, 2018Consumer Health Care Division/BOI
2
Health, life, disability, LTC, Medicare supplement (Medigap),
annuities
Ensures that forms from insurers to consumers comply with
statutes and regulations.
Assists Maine consumers having problems with their fully‐
insured plans.
Provides information/answers questions about insurance,
rights, and responsibilities.Maine Health Insurance Market: Insured Lives
3
100,000
90,000
80,000
70,000
60,000
50,000 Individual
40,000
Small Group
30,000
20,000
10,000
0
2013 2014 2015 2016 2017 2018Maine Guaranteed Access Reinsurance Association
(MGARA)
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Purpose: stabilize and reduce premiums in
individual market
18 mos. of MGARA prior to ACA: premiums 20%
lower than would otherwise have been
ACA Section 1332 “State Innovation Waiver”
application
MGARA Board – voted to implement for 2019How MGARA Works:
5
Carrier pro‐actively cedes coverage of high‐cost individuals to
MGARA
MGARA pays 90% of claims $47‐77K, and 100% of claims >
$77K
Funding:
Premiums of those ceded
$4 PMPM assessment
Decreased subsidies from decreased premiums –> Federal
Government passes through those dollars back to MGARA
Estimated premium reduction: 9%Example: 2019 Second Lowest Silver With & Without MGARA
6
Age 21‐Rates Without MGARA With MGARA Difference
Area 1
$435.88 $379.22 13.0% $56.66
Cumberland, Sagadahoc, York
Area 2
$470.48 $398.19 15.4% $72.29
Knox, Lincoln, Oxford, Kennebec
Area 3
$493.54 $419.03 15.1% $74.51
Androscoggin, Franklin, Waldo
Area 3
$511.81 $467.69 8.6% $44.12
Penobscot, Piscataquis, Somerset
Area 4
$659.10 $560.77 14.9% $98.33
Aroostook, Hancock, Washington2019 Individual and Small Group
Health Insurance Rate Filings
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Individual Rate Filings 2019
With MGARA
Companies Average
Minimum Maximum
Rate Increase
Anthem ‐ 15.9% 3.0%
‐4.3%
Community Health Options ‐ 2.52% 3.66%
0.9%
Harvard‐HMO 2.1% ‐4.4% 3.6%
Small Group Rate Filings 2019
With MGARA
Average Rate
Companies Increase Minimum Maximum
Aetna Health 12.1% 5.0% 21.0%
Aetna Life 7.0% 0.0% 8.1%
Anthem 11.0% 4.2% 19.3%
Community Health Options 8.4% 5.2% 13.8%
Harvard and HPHC 14.8% 5.1% 20.4%
United Healthcare 2.2% ‐8.5% 13.2%2019 Plans By Network Type, Metal Level & Carrier
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2019 Plans By Metal Level Offered By Each Carrier
Insurance Carrier Bronze Silver Gold Catastrophic Network Types On Off
Exchange Exchange
Anthem Blue Cross √ √ √ √ HMO (South) X X
Blue Shield
(800) 547‐4317 √ √ √ √ POS (North) X X
www.anthem.com
Maine Community √ √ √ HMO X X
Health Options (MCHO)
(855) 624‐6463 √ √ √ √ PPO X X
www.maineoptions.org
Harvard Pilgrim √ √ √ HMO X X
Health Care/
(888) 333‐4742
www.harvardpilgrim.orgBOI 2019 Individual Market Rate Calculator
9Federal Guidance on Health
Policies Is in the News
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S H O R T T E R M H E A LT H P L A N S
A S S O C I AT I O N H E A LT H P L A N SShort‐Term Health Insurance: ME requirements
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Term: < 12 mos.
24‐month limit (same or different carriers)
Nonrenewable
Subject to state mandated benefits
Preventive coverage
Prohibition against aggregate dollar limits
MLR minimum: 50%
Forms and rates must be pre‐approved
Written disclosure by carrier or producerShort Term Plans in Maine
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Independence American Insurance Company
National Health Insurance Company
Standard Security Life Insurance CompanyAssociation Health Plans
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New Federal rule does not preempt Maine law
Association groups
Multiple Employer Welfare Arrangements (MEWAs)
Self Insured
Fully InsuredNew State Statutes to Know
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2 0 1 7 & 2 0 1 8 L E G I S L AT U R EPublic Law 2017, Chapter 218
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An Act to Protect Maine Consumers from Unexpected Medical Bills
An enrollee receiving a surprise bill from an out‐of‐network (OON)
provider is only required to pay the out‐of‐pocket expense as if the
service was rendered by an in‐network provider.
“Surprise bill”:
‐ service rendered by OON provider at an in‐network facility, or
‐ service rendered by OON provider was approved by the insurer,
and
‐ patient did not knowingly choose to have service from that OON
provider.
Reimbursement rate for OON service is set at the in‐network rate unless
the insurer and provider agree otherwise.Public Law 2017, Chapter 232
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Health care transparency tools: website and toll free number for cost and
quality data for services from network providers; or carrier can direct
members to Maine Health Data Organization (MHDO) website.
Denial of referral: Cannot deny payment for covered service on basis that
referral was made by OON provider.
Incentives to shop: Incentivize enrollees in small groups to comparison
shop for “comparable health care services” from low‐cost, high‐quality
providers. “Comparable health care service” ‐ nonemergency, outpatient:
‐physical and occupational therapy
‐radiology and imaging
‐ laboratory
‐infusion therapyPublic Law 2018, Chapter 340 ‐ Naturopaths
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Sec. 1. 24‐A MRSA §4320‐K . Coverage for services provided by a naturopathic doctor
A carrier offering a health plan in this State shall provide coverage for health care services
performed by a naturopathic doctor licensed under Title 32, chapter 113‐B, subchapter 3 when
those services are covered services under the health plan when performed by any other health
care provider and when those services are within the lawful scope of practice of the
naturopathic doctor.
Network participation. A carrier shall demonstrate that the carrier's provider network includes
reasonable access, in accordance with section 4303, to all covered services that are within the
lawful scope of practice of a naturopathic doctor. A carrier may not exclude a provider from
participation in the carrier's provider network solely because the provider is a naturopathic
doctor as long as the provider is willing to meet the same terms and conditions as other
participating providers. This subsection does not require a carrier to contract with all
naturopathic doctors or require a carrier to provide coverage under a health plan for any
service provided by a participating naturopathic doctor that is not within the health plan's
scope of coverage.Maine Bureau of Insurance
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M A I N E .G OV/ P F R / I N S U R A N C E
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