July 22, The Honorable Henry A. Waxman Chairman Committee on Energy and Commerce House of Representatives

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1 United Sttes Government Accountbility Office Wshington, DC July 22, 2009 The Honorble Henry A. Wxmn Chirmn Committee on Energy nd Commerce House of Representtives The Honorble John D. Dingell Chirmn Emeritus Committee on Energy nd Commerce House of Representtives The Honorble Frnk Pllone, Jr. Chirmn Subcommittee on Helth Committee on Energy nd Commerce House of Representtives Subject: Helth Insurnce: Enrollment, Benefits, Funding, nd Other Chrcteristics of Stte High-Risk Helth Insurnce Pools A growing number of sttes 35 s of June 2009 hve creted high-risk helth insurnce pools (s) primrily to provide coverge to individuls whose helth sttus limits their ccess to coverge in the privte individul helth insurnce mrket. 1 s typiclly stterun nonprofit ssocitions often contrct with privte helth insurnce crrier to dminister the pool nd offer rnge of helth pln options to such individuls, who re commonly referred to s mediclly uninsurble. 2 Pln options vry within pools nd from stte to stte, nd like the privte individul mrket, s typiclly impose witing periods 1 Prticipnts in the privte individul mrket include self-employed people; people whose employers do not offer helth insurnce coverge; people not in the lbor force; erly retirees who no longer hve employment-bsed coverge nd re not yet eligible for Medicre; nd people who lose their jobs nd hve exhusted or re ineligible for continution of employer-bsed coverge. 2 Individuls who due to preexisting helth condition hve been rejected for coverge or chrged higher premiums in the privte individul mrket re typiclly eligible for coverge. Other groups of individuls my lso be eligible for coverge. Sttes my use s to implement the group mrket to individul mrket portbility provision of the Helth Insurnce Portbility nd Accountbility Act (HIPAA) of Pub. L. No , title I, 111, 110 Stt. 1936, HIPAA requires tht individuls with prior group coverge must hve continued ccess to nongroup coverge with ny preexisting condition witing periods wived. In ddition, sttes cn designte s s qulified helth coverge for displced workers nd retirees eligible for the federl Helth Coverge Tx Credit, under the Trde Adjustment Assistnce Reform Act of Pub. L. No , Div. A, 201 (), 116 Stt. 935, 954.

2 for coverge of preexisting conditions to discourge mediclly uninsurble individuls from foregoing helth insurnce until they require cre. 3 Becuse of the higher helth cre costs typiclly incurred by mediclly uninsurble individuls, ll pools operte t loss. Premiums for helth plns re higher thn for plns offered to helthy individuls in the privte helth insurnce mrket; however, these premiums re cpped to limit enrollees costs nd re thus insufficient to cover the costs of enrollee helth cre clims. 4 As result, ll s supplement their revenues through vrious funding mechnisms, such s ssessments on helth insurnce crriers nd stte generl revenues. Federl grnts re lso wrded to estblish nd fund s. As prt of the Trde Adjustment nd Assistnce Reform Act of 2002, Congress estblished progrm to provide grnts to s to offset losses nd estblish s commonly referred to s opertionl nd seed grnts, respectively. 5 Subsequent legisltion uthorized funding for the progrm through 2010, including grnts to be used for supplementl consumer benefits commonly referred to s bonus grnts. 6 Since 2003, the grnt progrm hs wrded nerly $286 million to stte s for vrious purposes. The Centers for Medicre & Medicid Services (CMS), within the Deprtment of Helth nd Humn Services (HHS), dministers this federl grnt progrm. Recent helth cre reform proposls cll for n expnded role for s to enhnce helth insurnce options for the mediclly uninsurble. Becuse of the federl funding provided to s, you expressed interest in obtining dt on severl spects of ech stte. In this report, we describe (1) enrollment nd enrollee demogrphics; (2) plns costshring provisions, coverge restrictions, nd premiums, nd comprble informtion for certin privte mrket helth plns; nd (3) s governnce, expenditures, nd funding. To ddress our three objectives, we dministered Web-bsed dt collection instrument (DCI) to senior officils of the 34 s in opertion in The dt obtined were generlly for fiscl yer 2008, lthough for certin questions we obtined dditionl historicl dt. Becuse ech offers multiple pln options to enrollees, in order to simplify comprisons of pln-specific cost-shring provisions, benefits, coverge restrictions, nd premiums, we limited mny of our comprisons to ech pool s most populr pln i.e., the pln chosen by the most enrollees. Collectively, the most populr plns covered 41 percent of 3 Most sttes offer wivers for the witing period for coverge of preexisting medicl conditions. Exmples of criteri to qulify for wiver often include involuntry termintion of coverge by previous crrier or previous creditble coverge within the pst 12 months, mong others. HIPAAeligible enrollees re not subject to preexisting condition restrictions. 4 Where funding is limited, n my need to restrict enrollment by vrious mens, such s by temporrily closing the pool to new enrollees or mintining witing list. 5 Pub. L , Div. A, 201(b), 116 Stt. 935, See, the Deficit Reduction Act of 2005, Pub. L , 6202, 120 Stt. 4, 134 (2006) nd the Stte High Risk Pool Funding Extension Act of 2006, Pub. L , 2, 120 Stt The Stte High Risk Pool Funding Extension Act uthorized totl of $75 million in opertionl nd bonus grnts for ech of fiscl yers 2006 through 2010 nd $15 million in seed grnts for fiscl yer Bonus grnts re to be used for supplementl consumer benefits such s premium subsidies, disese mngement progrms, nd expnsion efforts. 7 We did not include the North Crolin in our DCI becuse it ws not opertionl until

3 the enrollees cross the 34 s. 8 To ensure the clrity nd precision of our DCI questions, we pretested the DCI with officils of the Ntionl Assocition of Stte Comprehensive Helth Insurnce Plns (NASCHIP), n orgniztion tht provides eductionl resources nd informtion to ssist stte s in their opertion. We lso received comments on the DCI from CMS officil involved in the federl grnt progrm. We received responses to the DCI from ll 34 s, lthough not every responded to every question in the DCI. We relied on the dt s reported by the s nd did not independently verify or evlute these dt. However, we reviewed ll responses for resonbleness nd consistency, nd we clrified pprent irregulrities by compring the dt to other sources, such s n nnul compendium of sttisticl informtion compiled by NASCHIP. In ddition, we followed up with stte representtives for clrifiction where necessry. Bsed on these ctivities, we determined these dt were sufficiently relible for the purpose of our report. We supplemented informtion obtined through the DCI with dditionl dt nd nlyses. For our first objective, we estimted the number of individuls potentilly eligible for enrollment becuse they were uninsured nd hd one or more preexisting helth condition. To do this, we used 2006 Medicl Expenditure Pnel Survey (MEPS) dt to determine the percentge of uninsured individuls with t lest one chronic condition tht ws dignosed or treted in We then pplied tht percentge to Current Popultion Survey (CPS) estimtes of the number of uninsured individuls in ech of the 34 sttes with s. 9,10 We ssessed the relibility of the MEPS nd CPS dt by reviewing relted documenttion nd by testing the MEPS dt to identify outliers, missing dt, nd other potentil sources of errors, nd we determined they were sufficiently relible for our purposes. For our second objective, we compred selected benefits nd coverge restrictions to those found in employersponsored helth insurnce plns by obtining dt from two nnul surveys the Kiser Fmily Foundtion nd Helth Reserch nd Eductionl Trust (KFF/HRET) Employer Helth Benefits Annul Survey nd the Mercer Ntionl Survey of Employer-Sponsored Helth Plns. 11 KFF/HRET presents nnul dt bsed on its survey of rndom smple of privte nd public-sector employers, which it implements from July through My ech yer. Mercer presents nnul dt bsed on its survey of rndom smple of privte-sector employers, which it implements in July of ech yer. For ech of these surveys, we reviewed 8 In this report, we refer to the primry policyholders s enrollees. 9 The MEPS nd CPS dt we used were the most currently vilble t the time we performed our work. We used the 2006 MEPS, which is set of lrge-scle surveys of fmilies nd individuls, their medicl providers, nd employers cross the United Sttes dministered by the Agency for Helthcre Reserch nd Qulity. MEPS collects informtion regrding individuls demogrphics, helth sttus, nd insurnce sttus, mong other chrcteristics. We lso used dt published in the U.S. Census Bureu s report, Income, Poverty, nd Helth Insurnce Coverge in the United Sttes: 2007, on the 3-yer verge ( ) of the uninsured popultions by stte. These dt were bsed on the CPS Annul Socil nd Economic Supplement, which is household survey tht collects demogrphic informtion, such s employment nd helth insurnce sttus, mong other chrcteristics. 10 Our estimte of individuls potentilly eligible for enrollment my be understted becuse we excluded from our MEPS nlysis individuls with conditions tht re not lwys chronic in nture or tht were dignosed or treted prior to Conversely, our estimte could be overstted to the extent it includes uninsured individuls who my not be eligible becuse they hd ccess to other privte or public coverge but chose not to enroll. The CPS estimtes of the uninsured in ech stte re subject to smpling error of plus or minus 1.3 percent t the 90 percent confidence level. 11 We compred benefits nd coverge restrictions to those in employer-sponsored plns becuse, ccording to model legisltion prescribed by the Ntionl Assocition of Insurnce Commissioners (NAIC), pln benefit levels nd deductibles should be comprble to coverge provided by lrge employers in the stte. NAIC model legisltion provides bsis for the uniform regultion of s throughout the sttes. 3

4 the survey instruments nd methodology nd determined tht the dt were sufficiently relible for our purposes. To compre trends in premiums to those in the privte helth insurnce mrket, we compred premium dt reported in our DCI to premium estimtes for the privte individul helth insurnce mrket published by Americ s Helth Insurnce Plns (AHIP) helth insurnce trde ssocition nd for the employersponsored helth insurnce mrket published by KFF/HRET. Finlly, for our third objective, we supplemented the funding informtion we obtined through the DCI with CMS documenttion on the federl grnts nd through interviews with the CMS officil who mnges these grnts. We did not independently verify or evlute informtion we received from CMS. We conducted our work from July 2008 to June 2009 in ccordnce with ll sections of GAO s Qulity Assurnce Frmework tht re relevnt to our objectives. The frmework requires tht we pln nd perform the enggement to obtin sufficient nd pproprite evidence to meet our stted objectives nd to discuss ny limittions in our work. We believe tht the informtion nd dt obtined, nd the nlysis conducted, provide resonble bsis for ny findings nd conclusions in this product. Results in Brief Enrollment nd Demogrphics of Those Enrolled enrollment enrollees nd their dependents totled 199,418 in the 34 s in We estimted nerly 4 million dditionl individuls to be potentilly eligible for enrollment in n bsed on their uninsured sttus nd preexisting helth conditions. 12 All s ccepted new pplicnts in 2008 except for Cliforni, which hd witing list of bout 1,030, nd Florid, which hs been closed to new enrollment since The verge ge of enrollees in 2008 ws 49 yers nd their verge length of enrollment ws 3 yers. Among the 6 s tht collected employment or income dt, 13 bout hlf of the enrollees were employed, nd the verge household income ws bout $41,000. Enclosure I provides dditionl informtion on enrollment nd enrollee demogrphics. Cost-shring Provisions, Coverge Restrictions, nd Premiums In 2008, the verge nnul deductible for the most populr pln offered by ech of the 34 s ws $1,593 lmost three times s high s the verge nnul deductible of $560 mong employer-sponsored helth insurnce plns. About 63 percent of enrollees in these most populr plns hd deductibles of $1,000 or greter. In comprison, lmost 88 percent of enrollees in employer-sponsored plns hd deductible of under $1,000 or no deductible. 12 GAO estimted the potentilly eligible popultion, including dependents, by (1) determining the percentge of uninsured individuls with t lest one chronic condition using 2006 MEPS dt, nd (2) pplying tht percentge to CPS estimtes of the 3-yer verge uninsured popultion in ech of the 34 sttes with n ( ). The CPS estimtes re subject to smpling error of plus or minus 1.3 percent t the 90 percent confidence level. 13 Employment informtion ws provided by Colordo, Mrylnd, Oregon, Uth, nd Wisconsin. Income informtion ws provided by Indin, Mrylnd, Oregon, Uth, nd Wisconsin for new enrollees only. 4

5 About 18 percent of enrollees in the 34 most populr plns in 2008 were in plns tht did not cover mternity cre nd bout 3 percent were in plns tht did not cover mentl helth services. Almost ll enrollees in the most populr plns hd ccess to prescription drug nd trnsplnt coverge. Fifteen percent of the most populr plns (5 plns) in 2008 hd nnul mximum coverge limits. These nnul limits rnged between $75,000 nd $300,000 nd verged $175,000. By comprison, 10 percent of employer-sponsored plns hd nnul limits. Almost 90 percent of the most populr plns (30 plns) hd lifetime dollr limits, which rnged between $500,000 nd $5,000,000 nd verged $1.6 million. By comprison, 56 percent of employer-sponsored plns hd lifetime limits. Between 2004 nd 2008, verge monthly premiums rose by 14 percent cross ll plns, from $424 to $485. During the period 2004 through 2006, verge monthly premiums incresed by 6 percent while verge premiums in the employer-sponsored helth insurnce nd the individul helth insurnce mrkets both incresed by 15 percent. During the period 2007 through 2008, verge monthly premiums incresed by 6 percent nd employersponsored mrket premiums incresed by 5 percent. No comprble individul mrket premium dt were vilble for these 2 yers. Fourteen percent of ll enrollees received income-bsed premium subsidies, which were offered by 12 s in The verge monthly subsidy received ws $261, or bout 49 percent of the subsidy recipients verge monthly premium of bout $538. Enclosure II provides dditionl informtion on cost-shring provisions, coverge restrictions, nd premiums. Governnce, Expenditures, nd Funding Collectively, in 2008, governing bords included representtives from helth insurnce crriers (41 percent of bord members), stte government (13 percent), medicl providers (9 percent), enrollees (7 percent), nd employers (3 percent), mong others. 14 Totl clims pid by s in 2008 were bout $1.9 billion, ccounting for lmost 95 percent of totl expenditures. The verge clims per enrolled individul totled $9,437 in 2008, n increse of bout 39 percent since In 2008, premium revenue contributed 54 percent of funding, nd insurnce crrier ssessments contributed bout 23 percent. s were wrded totl of pproximtely $286 million in federl grnts between 2003 nd 2008, ccording to CMS. Almost 83 percent of these funds were opertionl grnts, lmost 15 percent were bonus grnts, nd less thn 3 percent were seed grnts. Federl grnts comprised less thn 2 percent of totl funding in Percentges provided re out of totl voting bord members. governing bords my lso include nonvoting members. 5

6 Of the $75 million in federl grnts tht s were wrded in 2006, bout 55 percent were used to cover opertionl losses, bout 17 percent to reduce premiums, nd bout 14 percent to support income-bsed premium subsidy progrms, ccording to reports submitted to CMS. s used the rest of the funds for vrious purposes, such s disese mngement progrms nd reduction in cost shring, incresing benefit coverge, nd mrketing nd outrech. 15 Enclosure III contins more informtion on governnce, expenditures, nd funding. Agency Comments We provided drft of this report to HHS nd NASCHIP for comment. In response, HHS provided written comments, stting tht our report contins welth of vluble informtion on s. We hve reproduced these comments in enclosure IV. HHS nd NASCHIP lso provided technicl comments, which we incorported s pproprite. As greed with your offices, unless you publicly nnounce its contents erlier, we pln no further distribution of this report until 30 dys from its issue dte. At tht time, we will send copies of this report to the Secretry of HHS, relevnt congressionl committees, nd other interested members. The report will lso be vilble t no chrge on GAO s Web site t John E. Dicken Director, Helth Cre Issues Enclosures 5 15 Such funds were next wrded in Annul reports on how s used these 2008 grnts were not vilble t the time of this report, so they were not included in our nlysis. 6

7 Enclosure I Enrollment nd Demogrphics of Enrollees, Fiscl Yer 2008 Tble 1: Enrollment in 2008 nd Estimte of the Potentilly Eligible Popultion, Stte s Totl enrollees Totl enrollees nd dependents Estimted number of individuls potentilly eligible for enrollment AL 2,272 2,410 79,632 AK ,490 AR 3,079 3,079 61,110 CA 6,809 7, ,720 CO 8,552 8, ,674 CT 2,073 2,336 43,344 FL ,948 ID 1,272 1,337 27,216 IL 16,063 16, ,610 IN 6,261 6,561 96,516 IA 2,732 2,732 34,524 KS 1,693 1,863 40,320 KY 4,185 4,354 71,694 LA 1,117 1, ,682 MD 11,366 14,691 95,886 MN 23,511 27,386 55,188 MS 3,468 3,468 68,418 MO 3,015 3,015 91,098 MT 3,016 3,016 18,900 NE 5,126 5,126 26,712 NH 1,038 1,094 17,388 NM 6,020 6,020 53,550 ND 1,463 1,463 8,568 OK 2,276 2,276 80,640 OR 13,953 15,318 78,246 SC 2,329 2,329 88,830 SD ,962 TN 3,768 3, ,580 TX 24,170 26, ,562 UT 3,621 3,621 50,274 WA 3,397 3,397 97,020 WV ,768 WI 16,284 16,284 60,480 7

8 Enclosure I Totl enrollees Totl enrollees nd dependents Estimted number of individuls potentilly eligible for enrollment WY ,198 Across ll s 186, ,418 3,968,748 Source: GAO dt collection instrument dministered to ll 34 s opertionl in 2008 nd nlysis of dt from the 2006 Medicl Expenditure Pnel Survey (MEPS) nd U.S Census Bureu, Income, Poverty, nd Helth Insurnce Coverge in the United Sttes: GAO estimted the potentilly eligible popultion, including dependents, by (1) determining the percentge of uninsured individuls with t lest one chronic condition using 2006 MEPS dt, nd (2) pplying tht percentge to Current Popultion Estimtes (CPS) estimtes of the 3-yer verge uninsured popultion in ech of the 34 sttes with n ( ). The CPS estimtes re subject to smpling error of plus or minus 1.3 percent t the 90 percent confidence level. The MEPS nd CPS dt used were the most current vilble t the time we performed our work. Tble 2: s with Witing Lists or Closed to Enrollment, Yer s with witing list (mximum number of individuls on the list) s closed to enrollment 2004 Illinois (279) Florid 2005 Illinois (173) Florid 2006 Cliforni (864) Florid 2007 Cliforni (232) Florid 2008 Cliforni (1,030) Florid Source: GAO dt collection instrument dministered to ll 34 s opertionl in

9 Enclosure I Tble 3: Demogrphics of Enrollees, by Stte, 2008 Employment sttus,b Percentge of enrollees who re: ge (yers) Employed Unemployed Retired household income of new enrollees c Percent mle length of enrollment (in months) Percent who re HIPAAeligible d Percent who re HCTCeligible e AL f 0.0 AK AR CA CO CT FL N/A g ID IL IN 48 $27, IA KS KY LA MD $35, MN MS MO MT NE NH NM ND OK OR $29, SC SD f 0.0 TN TX UT $70, WA WV WI $54,200 h WY Across ll s 49 i $41,136 i i Source: GAO dt collection instrument dministered to ll 34 s opertionl in Legend: = response not provided N/A: Not pplicble 9

10 Enclosure I Note: Informtion presented for enrollees only not dependents, with the exception of Texs where dependents re counted s enrollees becuse they hold their own policies. Employment sttus ws provided by five sttes Colordo nd Wisconsin collected these dt from new enrollees only, nd Mrylnd, Oregon, nd Uth collected it from ll enrollees. b Percentges my not dd to 100 becuse some enrollees my fll into other or unknown employment sttus ctegories. c income ws provided by the five s tht collected income dt for new enrollees in d HIPAA-eligible refers to those individuls who qulify for enrollment becuse of the Helth Insurnce Portbility nd Accountbility Act of 1996, which llows for portbility of helth coverge for those with prior group coverge. e HCTC-eligible refers to those individuls who qulify for enrollment becuse of the Helth Coverge Tx Credit, which provides tx credits for helth insurnce premiums for certin eligible displced workers nd retirees. f Pool is open to HIPAA-eligibles only. g The Florid hs been closed to new enrollment since 1991 nd, in 2008, hd 292 enrollees. h Income dt were provided on voluntry bsis by 77 percent of new enrollees in Wisconsin. i s re weighted bsed on enrollment. 10

11 Enclosure II Pln Cost-shring Provisions, Benefits, Coverge Restrictions, nd Premiums Tble 4: Annul Deductible of Most Populr Plns Compred to Employer-sponsored Plns, 2008 Most populr plns Employer-sponsored plns b nnul deductible $1,593 c $560 Source: GAO dt collection instrument dministered to ll 34 s opertionl in 2008 nd Kiser Fmily Foundtion nd Helth Reserch & Eductionl Trust, Employer Helth Benefits: 2008 Annul Survey (Menlo Prk, Clif., nd Chicgo, Ill.: 2008). Note: Deductibles re for self-only coverge nd in-network services. This includes the most populr pln the pln with the most enrollees in ech of the 34 s. The most populr plns hd totl of 76,846 enrollees, ccounting for 41 percent of totl enrollees in b Preferred provider orgniztion pln types. c ws weighted by the number of enrollees in the 33 most populr plns tht hd deductibles greter thn zero. Tble 5: Distribution of Enrollees by Annul Deductible Level in All Plns nd Most Populr Plns, Compred to Employer-sponsored Plns, 2008 s All plns Most populr plns Employer-sponsored plns b Annul deductible Percentge of totl enrollees c Percentge of totl enrollees c Percentge of covered workers in employersponsored plns d No deductible $1 $ $500 $ $1,000 $1, $2,000 $2, $3,000 $4, $5,000 or more e Source: GAO dt collection instrument dministered to ll 34 s opertionl in 2008 nd Kiser Fmily Foundtion nd Helth Reserch & Eductionl Trust, Employer Helth Benefits: 2008 Annul Survey (Menlo Prk, Clif., nd Chicgo, Ill.: 2008). Note: Deductibles re for self-only coverge nd in-network services. Informtion presented for enrollees only not dependents, with the exception of Texs where dependents re counted s enrollees becuse they hold their own policies. This includes the most populr pln the pln with the most enrollees in ech of the 34 s. The most populr plns hd totl of 76,846 enrollees, ccounting for 41 percent of totl enrollees in b Preferred provider orgniztion pln types. c Percentges do not dd to 100 becuse enrollees in supplementl insurnce plns were excluded. d Percentges do not dd to 100 due to rounding. e Dt for employer-sponsored plns were only vilble for deductibles of $2,000 or more. 11

12 Enclosure II Tble 6: Distribution of Enrollees in Most Populr Plns, by Annul Out-of-pocket Spending Limits, 2008 Annul out-of-pocket spending limits in most populr plns Percentge of ll enrollees in most populr plns Less thn $2, $2,001 $5, $5,001 $7, $7,001 $10, More thn $10,000 0 Totl 100 Source: GAO dt collection instrument dministered to ll 34 s opertionl in Notes: Anlysis includes the most populr pln the pln with the most enrollees in ech of the 34 s. The most populr plns hd totl of 76,846 enrollees, ccounting for 41 percent of totl enrollees in Informtion on out-of-pocket spending limits ws provided for self-only coverge nd in-network services. Informtion presented for enrollees only not dependents, with the exception of Texs where dependents re counted s enrollees becuse they hold their own policies. Percentges do not dd to 100 due to rounding. 12

13 Enclosure II Tble 7: Annul Out-of-pocket Spending Limit in Ech Stte s Most Populr Pln, nd Costs tht Could Exceed the Limit, 2008 AL Annul out-ofpocket spending limit N/A Overll nnul deductible Seprte hospitl deductible Seprte prescription drug deductible Cost-shring fetures Seprte mentl helth deductible Coinsurnce Copy for prescription drugs Copy for mentl helth Copy for physicin office visits AK $10,000 AR $2,000 CA $2,500 CO $2,000 CT $7,500 FL ID $10,000 IL $1,500 IN $1,500 IA $5,000 KS $3,000 KY $4,000 LA $9,500 MD $3,000 MN $3,000 MS N/A MO $5,000 MT $7,500 NE $3,500 NH $3,500 NM $2,500 ND $3,000 OK $10,000 OR $1,500 SC $5,000 SD $3,250 TN $5,000 TX $5,500 UT $2,000 WA $1,500 WV $3,000 WI $3,500 WY $2,000 Source: GAO dt collection instrument dministered to ll 34 s opertionl in 2008 Legend: = Cost is not subject to the nnul out-of-pocket mximum = Cost is subject to the nnul out-of-pocket mximum 13

14 Enclosure II N/A = Not pplicble becuse the most populr pln did not hve n nnul out-of-pocket mximum = Response not provided Notes: Blnk cells indicte tht the cost ws not feture of the pln s cost-shring structure. Anlysis includes the most populr pln the pln with the most enrollees in ech of the 34 s. The most populr plns hd totl of 76,846 enrollees, ccounting for 41 percent of totl enrollees in Informtion on out-of-pocket spending limits ws provided for self-only coverge nd in-network services. Mississippi does not hve n overll policy regrding the out-of-pocket mximum, but it hs $5,000 out-of-pocket mximum on llowble hospitl chrges, fter which the policy pys llowble hospitl chrges t 100 percent. Tble 8: Coverge of Selected Benefits Among Most Populr Plns Compred to Employersponsored Plns, 2008 Most populr plns,b Percentge of enrollees c in plns tht cover benefit Employersponsored plns Percentge of workers in plns tht cover benefit Number of plns Benefit tht cover benefit Mternity cre NA Mternity cre covered s rider d 4 10 NA Trnsplnts e NA Mentl helth services Prescription drugs Source: GAO survey of 34 s opertionl in 2008 nd Kiser Fmily Foundtion nd Helth Reserch & Eductionl Trust, Employer Helth Benefits: 2008 Annul Survey (Menlo Prk, Clif., nd Chicgo, Ill.: 2008). Legend: NA = Not vilble This includes the most populr pln the pln with the most enrollees in ech of the 34 s. The most populr plns hd totl of 76,846 enrollees, ccounting for 41 percent of totl enrollees in b Informtion is for in-network services nd individul (not fmily) coverge only. Supplementl insurnce policies re excluded. c Informtion presented for enrollees only not dependents, with the exception of Texs where dependents re counted s enrollees becuse they hold their own policies. d Privte individul helth insurnce plns my offer optionl coverge of dditionl services, such s mternity cre. This extr coverge is referred to s n optionl rider. e The percentge of enrollees with coverge of trnsplnts ws 99.7, which rounds to

15 Enclosure II Tble 9: Selected Cost-shring Fetures nd Coverge Limits Among Most Populr Plns Compred to Employer-sponsored Plns, 2008 Cost-shring fetures nd limits on coverge Most populr plns,b Number of plns Percentge of enrollees in plns with feture nd/or limit c Employer-sponsored plns Percentge of covered workers in plns with feture nd/or limit d Seprte cost shring for inptient hospitl cre, in ddition to the overll pln deductible Preventive services exempt from pln deductible Seprte prescription drug deductible for plns tht cover prescription drugs Required coinsurnce for prescription drugs for plns tht cover prescription drugs NA Out-of-pocket nnul mximums tht pply to cost shring for prescription drugs for plns tht cover prescription drugs Thirty or less mentl helth outptient visits covered in yer by plns tht cover mentl helth benefits 13 e f Additionl cost shring for emergency room cre NA Source: GAO dt collection instrument dministered to ll 34 s opertionl in 2008 nd Kiser Fmily Foundtion nd Helth Reserch & Eductionl Trust, Employer Helth Benefits: 2008 Annul Survey (Menlo Prk, Clif., nd Chicgo, Ill.: 2008). Legend: NA = Not vilble This includes the most populr pln the pln with the most enrollees in ech of the 34 s. The most populr plns hd totl of 76,846 enrollees, ccounting for 41 percent of totl enrollees in b Informtion is for in-network services nd individul (not fmily) coverge only. Supplementl insurnce policies re excluded. c Informtion presented for enrollees only not dependents, with the exception of Texs where dependents re counted s enrollees becuse they hold their own policies. d Preferred provider orgniztion pln types. e Such limits my pply to some mentl helth services only. For exmple, the New Mexico reported tht its mentl helth limits pply only to chemicl dependency services. f Informtion for mentl helth outptient visits is for covered workers with outptient mentl helth coverge nd not specified for in- or out-of-network coverge. 15

16 Enclosure II Tble 10: Annul nd Lifetime Dollr Limits Among Most Populr Plns Compred to Employersponsored Plns, 2008 Type of Limit limit Rnge in limits Most populr plns,b Number of enrollees c who met limit Number of plns with limit Percentge of plns with limit Employersponsored plns Percentge of employersponsored plns with limit d Annul dollr limit $175,000 $75, , e Lifetime dollr limit $1.6 million $500,000 5 million f g Source: GAO dt collection instrument dministered to ll 34 s opertionl in 2008 nd Mercer, Ntionl Survey of Employer-Sponsored Helth Plns, This includes the most populr pln the pln with the most enrollees in ech of the 34 s. The most populr plns hd totl of 76,846 enrollees, ccounting for 41 percent of totl enrollees in b Informtion is for in-network services nd individul (not fmily) coverge only. Supplementl insurnce policies re excluded. c Informtion presented for enrollees only not dependents, with the exception of Texs where dependents re counted s enrollees becuse they hold their own policies. d Among preferred provider orgniztion nd point-of-service plns offered by employers with 10 or more employees. e The five s tht hd nnul limits were: Cliforni, Louisin, Tennessee, Uth, nd West Virgini. In ddition, while some s my not hve hd overll nnul limits, they my hve hd nnul limits on specific services. For exmple, Mississippi told us tht while it did not hve n overll nnul limit in 2008, it hd n nnul phrmcy limit of $100,000 in Similrly, New Mexico hd nnul limits on cupuncture, dibetic eduction services, therpy/rehbilittion, nd nnul wellness preventive benefits. f s my hve hd lifetime limits on individul services. For exmple, New Mexico reported tht while it did not hve n overll lifetime limit, it hd $5 million lifetime limit on trnsplnts nd $2,500 limit on dibetic eduction services. g Medin lifetime limit ws $2,000,

17 Enclosure II Tble 11: Monthly Premiums, by Stte, premium rte s percent of stndrd mrket rte monthly premium b monthly premium for 50-yer-old nonsmoking mle c premium rte s percent of stndrd mrket rte monthly premium b monthly premium for 50-yer-old nonsmoking mle c premium rte s percent of stndrd mrket rte monthly premium b monthly premium for 50-yer-old nonsmoking mle c AL 98 $448 $ $486 $ $539 $478 AK AR CA CO CT FL ID IL IN IA KS KY LA MD MN MS MO MT NE NH NM ND OK OR SC SD TN TX UT WA WV WI d WY

18 Enclosure II premium rte s percent of stndrd mrket rte monthly premium b monthly premium for 50-yer-old nonsmoking mle c premium rte s percent of stndrd mrket rte monthly premium b monthly premium for 50-yer-old nonsmoking mle c premium rte s percent of stndrd mrket rte monthly premium b monthly premium cross ll s e $424 $431 $450 monthly premium for 50-yer-old nonsmoking mle c Source: GAO dt collection instrument dministered to ll 34 s opertionl in Legend: = response not provided In generl, ech sets premiums s percentge of stndrd mrket rte, which is bsed on the premium rtes chrged by other privte individul mrket helth insurnce crriers offering coverge in its stte. b s clculted verge premiums by dividing the totl premium revenue in ech yer by the verge number of enrollees for the yer, with the exception of Texs which lso included dependents in its clcultion becuse they hold their own policies. The clcultion excludes supplementl plns. c premium is for 50-yer-old nonsmoking mle with self-only coverge who is enrolled in tht stte s most populr pln the one with the most enrollees. d Wisconsin does not set its premiums s percent of the stndrd rte. e s re weighted bsed on enrollment. 18

19 Enclosure II Tble 11b: Monthly Premiums, by Stte, Continued, premium rte s percent of stndrd mrket rte monthly premium b monthly premium for 50-yer-old nonsmoking mle c premium rte s percent of stndrd mrket rte monthly premium b monthly premium for 50-yer-old nonsmoking mle c AL 126 $556 $ $571 $540 AK AR CA CO CT FL ID IL IN IA KS KY LA MD MN MS MO MT NE NH NM ND OK OR SC SD TN TX UT WA WV WI d WY

20 Enclosure II premium rte s percent of stndrd mrket rte monthly premium b monthly premium for 50-yer-old nonsmoking mle c premium rte s percent of stndrd mrket rte monthly premium b monthly premium cross ll s e $460 $485 monthly premium for 50-yer-old nonsmoking mle c Source: GAO dt collection instrument dministered to ll 34 s opertionl in Legend: = response not provided In generl, ech sets premiums s percentge of stndrd mrket rte, which is bsed on the premium rtes chrged by other privte individul helth insurnce crriers offering coverge in its stte. b s clculted verge premiums by dividing the totl premium revenue in ech yer by the verge number of enrollees for the yer, with the exception of Texs which lso included dependents in its clcultion becuse they hold their own policies. The clcultion excludes supplementl plns. c premium is for 50-yer-old nonsmoking mle with self-only coverge who is enrolled in tht stte s most populr pln the one with the most enrollees. d Wisconsin does not set its premiums s percent of the stndrd mrket rte. e s re weighted bsed on enrollment. 20

21 Enclosure II Tble 12: Chnge in Monthly Premiums for ll s Compred to Privte Helth Insurnce Mrket Premiums, 2004 to 2008 Employer-sponsored mrket 2004 through through through 2008 Percentge Percentge Percentge chnge chnge chnge $308 $ $373 $ Individul mrket $189 $218 b 15 NA NA NA NA c,d $424 $450 6 $460 $ Sources: GAO dt collection instrument dministered to ll 34 s opertionl in 2008; Americ s Helth Insurnce Plns (AHIP) Center for Policy nd Reserch, Individul Helth Insurnce: A Comprehensive Survey of Affordbility, Access, nd Benefits, August 2005, (Wshington, D.C.: 2005), nd Individul Helth Insurnce : A Comprehensive Survey of Premiums, Avilbility, nd Benefits (Wshington, D.C.: 2007); Kiser Fmily Foundtion nd Helth Reserch & Eductionl Trust, Employer Helth Benefits: 2004, 2006, 2007, nd 2008 Annul Surveys (Menlo Prk, Clif., nd Chicgo, Ill.: 2004, 2006, 2007, nd 2008 respectively). Legend: NA = Not vilble According to model legisltion prescribed by the Ntionl Assocition of Insurnce Commissioners, n should consider bsing premiums on the stndrd mrket rtes chrged in the individul mrket in its stte. b AHIP individul mrket premium dt re mostly s of December 2006 nd Jnury c s clculted verge premiums by dividing the totl premium revenue in ech yer by the verge number of enrollees for the yer, with the exception of Texs which lso included dependents in its clcultion becuse they hold their own policies. The clcultion excludes supplementl plns. In ddition, monthly verges were weighted by the number of enrollees cross ll plns tht responded. d Tble shows rounded numbers for verge monthly premiums. However, percentge chnge numbers were clculted using non-rounded numbers. 21

22 Enclosure II Tble 13: Income-bsed Premium Subsidies Offered by s, 2008 Subsidy recipients Mximum household income eligible for subsidy s percentge of FPL discount s percentge of monthly premium monthly discount Mximum discount vilble s percentge of monthly premium CO 3, $ IN MD 4, MN b 2, MT NM 2, OR 4, TN 3, UT WA WI c 3, WY Across ll s 25,715 d 285% 49% e $261 e 66 e Source: GAO dt collection instrument dministered to ll 34 s opertionl in Legend: = response not provided Note: Informtion presented for the 12 s tht reported tht they provided income-bsed premium subsidies. Other s my lso offer income-bsed subsidies tht re not relted to premiums. Federl Poverty Level (FPL). b Minnesot s subsidy progrm is not tied directly to the mount of premium or percent of premium n enrollee pys; rther, it is progrm tht provides subsidy once yer. If enrollees qulify t 220 percent of the FPL bsed on household size, they receive one check per enrollee nd dependent. They re not required to use these funds towrd premium pyment. For exmple, funds cn be used for other purposes such s pying coinsurnce, or deductible mounts due to providers. The progrm includes enrollees nd dependents on ll plns including Medicre. c The income limit for Wisconsin s subsidy progrm ws not expressed reltive to the FPL, but to level of household income. In clendr yer 2008, the mximum income eligible ws $25,000. d Fourteen percent of ll enrollees were receiving income-bsed premium subsidies. e is weighted by number of subsidy recipients. 22

23 Enclosure II Tble 14: Income-bsed Premium Subsidy Recipients by Deductible Level, 2008 Deductible level Number of subsidy recipients enrolled No deductible 229 $1 $499 2,218 $500 $999 9,186 $1,000 $1,999 5,851 $2,000 $2,999 3,348 $3,000 $4, $5,000 or more 1,538 Source: GAO dt collection instrument dministered to ll 34 s opertionl in Note: Informtion presented for the 12 s tht reported tht they provided income-bsed premium subsidies. Deductible informtion ws not provided for ll subsidy recipients. 23

24 Enclosure III Governnce, Expenditures, nd Funding Tble 15: Composition of Bords of Directors Across All 34 s, 2008 Group Voting members s percentge of totl Nonvoting members s percentge of totl Employers 3 5 Enrollees 7 0 Insurnce crriers 41 2 Medicl providers 9 15 Stte government Other Source: GAO dt collection instrument dministered to ll 34 s opertionl in Other members of bords of directors include members of insurnce nd medicl representtive ssocitions, the generl public, nd disbility gents, mong others. 24

25 Enclosure III Tble 16: Composition of Bords of Directors by Stte, 2008 Employers Enrollees Insurnce crriers Medicl providers Stte government Other Voting Nonvoting Voting Nonvoting Voting Nonvoting Voting Nonvoting Voting Nonvoting Voting Nonvoting AL AK 5 2 AR CA 5 3 CO CT 9 FL ID IL IN IA KS KY 1 1 LA MD MN MS MO MT 1 7 NE NH NM ND 3 5 OK OR SC 5 3 SD TN TX UT WA WV WI WY Source: GAO dt collection instrument dministered to ll 34 s opertionl in Other members of bords of directors include members of insurnce nd medicl representtive ssocitions, the generl public, nd disbility gents, mong others. 25

26 Enclosure III Tble 17: Expenditures by Stte, 2003 nd 2008 (dollrs in thousnds) Yer Medicl Mentl helth services Pid clims Prescription drugs Totl clims Administrtive expenses b Other expenditures Totl expenditures c AL 2003 $23,991 $23,991 $263 $19 $24, ,225 21, ,612 AK ,749 $909 6, , ,558 $ , ,906 AR ,375 21,375 2, , ,635 19,635 2,386 22,021 CA ,565 97,565 4, , ,201 39,201 2,507 41,708 CO ,876 5,568 30,444 3,007 33, ,401 11,227 62,628 5,302 67,930 CT ,391 22, ,164 24, ,108 7,543 35, ,098 37,270 FL , , , , , ,306 ID , , , , ,578 1, ,079 IL ,814 25, ,059 6, , ,607 40, ,128 8, ,011 IN , , ,046 4, , , ,810 96,910 3, ,488 IA , , , ,392 31,459 1, ,101 KS ,488 1,485 12, , ,334 2,930 22, ,438 KY , ,802 14,591 1, , , ,654 47,272 3, ,433 LA , ,570 13, , , ,791 9,576 1, ,094 MD 2003 d ,829 1,817 28, ,511 6, ,880 MN ,049 9, , ,904 49, ,773 10,207 1, ,540 MS , ,524 23,757 1, , , ,625 23,018 1, ,615 MO ,666 5,062 16,728 2, , ,407 8,387 24,794 2, ,644 MT ,369 3,481 13,850 1, , ,968 4,539 25,507 1, ,882 26

27 Enclosure III Yer Medicl Mentl helth services Pid clims Prescription drugs Totl clims Administrtive expenses b Other expenditures Totl expenditures c NE , ,657 44,871 2, , , ,827 54,920 2, ,576 NH , , , , ,103 12, ,027 NM ,136 2,924 10, , , ,189 60,853 2, ,282 ND , , , ,722 OK , ,993 23,361 1, , , ,320 24,333 1, ,571 OR ,624 1,508 13,961 61,092 3, , ,324 7,252 30, ,029 7, ,011 SC ,973 18,973 1, , ,630 26,630 1, ,433 SD ,707 1,518 5, ,614 TN , ,675 25,118 2, ,477 TX ,682 52, ,378 14, , ,337 80, ,547 13, ,262 UT ,275 3,808 16,083 1,340 17, ,021 4,975 25,996 1,782 27,778 WA ,493 1, , , ,490 55,208 3, ,775 WV , , ,066 WI ,444 4, , ,458 33, ,822 6, ,352 WY ,568 4, , ,511 7, ,899 Totl ,965 1, ,364 1,215,075 71,752 3,479 1,290, ,417,216 11, ,646 1,882, ,982 8,226 1,991,803 Percent chnge e Source: GAO dt collection instrument dministered to ll 34 s opertionl in Legend: = response not provided Where mentl helth services clims re not provided, they re included in the medicl clims. b My include third-prty dministrtive fees, cturil fees, legl fees, gent fees, etc. c Totls my not dd due to rounding. d The Mrylnd did not begin providing helth insurnce coverge until fiscl yer e While this tble presents expenditure figures in rounded numbers (thousnds), the percentge chnge numbers were clculted bsed on non-rounded expenditure numbers. 27

28 Enclosure III Tble 18: Clims per Enrolled Individul, by Stte, 2003 nd AL $6,114 $8,807 AK 13,755 11,496 AR 6,485 6,377 CA 12,609 5,572 CO 6,251 7,323 CT 9,778 15,262 FL 8,406 12,590 ID 4,369 9,407 IL 6,668 9,720 IN 11,355 13,864 IA 13,806 11,515 KS 7,618 11,951 KY 5,939 10,857 LA 10,047 8,573 MD 0 7,250 MN 5,194 8,974 MS 5,603 6,637 MO 6,856 8,224 MT 4,553 8,457 NE 7,274 10,714 NH 9,868 11,137 NM 8,383 10,108 ND 4,479 7,070 OK 8,211 10,691 OR 6,180 10,643 SC 10,546 11,434 SD b 7,810 TN c 6,666 TX 7,189 9,757 UT 5,661 7,179 WA 14,138 16,252 WV d 4,109 WI 6,330 9,630 WY 7,016 10,490 Across ll s $ 6,795 e $9,437 e Source: GAO dt collection instrument dministered to ll 34 s opertionl in 2008 nd GAO nlysis of dt from the Ntionl Assocition of Stte Comprehensive Helth Insurnce Plns, Comprehensive Helth Insurnce for High-Risk Individuls: A Stte-by-Stte Anlysis, 2008/2009. Legend: = response not provided Note: GAO clculted verge clims bsed on n nlysis of totl clims nd totl enrollment including dependents for ll stte s except for Indin, which directly provided us verge clims dt. Mrylnd s ws first estblished in b South Dkot s ws first estblished in c Tennessee s did not exist in

29 Enclosure III d West Virgini s did not exist in e s weighted by totl enrollment. Tble 19: Sources of Funding Ntionwide, 2003 nd 2008 (in thousnds) Type of funding ($) Percentge of totl funding ($) Percentge of totl funding Premiums 763, , Assessments on helth 428, , insurnce crriers Other ssessments 28, , Stte generl revenues 16, , Stte tobcco tx 40, , Federl grnts 1, , Other 52, , Totl 1,331, ,819, b Source: GAO dt collection instrument dministered to ll 34 s opertionl in Federl grnts were wrded by the Centers for Medicre & Medicid Services. b Totls do not sum to 100 percent due to rounding. 29

30 Enclosure III Tble 20: Sources of Funding by Stte, 2003 nd 2008 Yer Premiums Assessments on crriers Percentge of totl funding Other ssessments Stte generl revenue Stte tobcco tx Federl grnts Other Totl funding for stte (in thousnds) AL $28, ,071 AK , ,420 AR , ,963 CA , ,927 CO , ,399 CT , ,205 FL , ,273 ID , ,079 IL , ,297 IN , ,616 IA , ,031 KS , ,754 KY , ,431 LA , ,512 MD , ,878 MN , ,651 MS , ,573 MO , ,848 MT , ,035 30

31 Enclosure III Yer Premiums Assessments on crriers Percentge of totl funding Other ssessments Stte generl revenue Stte tobcco tx Federl grnts Other Totl funding for stte (in thousnds) NE , ,781 NH , ,298 NM , ,210 ND , ,797 OK , ,202 OR , ,452 SC , ,719 SD ,930 TN ,255 TX , ,262 UT , ,982 WA , ,664 WV ,862 WI , ,766 WY , ,377 Source: GAO dt collection instrument dministered to ll 34 s opertionl in Legend: = response not provided Federl grnts were wrded by the Centers for Medicre & Medicid Services (CMS). Percentges re bsed on wrds vilble but my not reflect funds ctully drwn down in tht yer. For exmple, ccording to the Minnesot, it ws wrded $1,984,248 in federl grnts in 2003; however, these funds were not drwn down until

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