Private Insurance Fundamentals: Health Insurance Coverage, the Market, and Insurance Regulation. Bernadette Fernandez February 25, 2011

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1 Private Insurance Fundamentals: Health Insurance Coverage, the Market, and Insurance Regulation Bernadette Fernandez February 25, 2011

2 Health Insurance Insurance provides protection from economic loss Risk likelihood and magnitude of loss Risk pools Pooling spreads risk across the members of the pool Features of good pools Many people in the pool Pool formation is NOT for insurance purposes Cohesive pool membership CRS-2

3 Sources of Health Coverage, % 56.6% 50% Employment Based Nongroup 40% Medicare 30% Medicaid and other Public Programs Military / Veterans 20% 10% 13.1% 14.4% 16.2% 4.6% 15.1% Indian Health Service Uninsured 0% 0.5% Note: Individuals can have coverage from more than one source; therefore, the sum of these estimates exceeds 100%. Source: U.S. Census Bureau, 2009 American Community Survey. CRS-3

4 Main Players Who purchases private coverage? Individuals and families Employers Average employer share of total premium, 2010 Self-only: 81% Family of four: 70% Who provides private coverage? Insurance carriers commercial, HMOs, Blues Employers who self insure CRS-4

5 Voluntary Nature of Private Market Employers are not required to offer health coverage State exceptions Offer rate: 69% (2010) Very large firms (200+ workers): 99% Very small firms (3-9 workers): 59% Individuals are not (yet) required to have health coverage Massachusetts exception Uneven distribution of health care expenditures Top 5% of population nearly 50% of expenditures (2008) Potential for adverse selection CRS-5

6 Adverse Selection Consumers Risk pool has disproportionate share of highcost individuals Consumer examples Waiting until sickness or injury to obtain insurance Switching from less generous coverage to more generous coverage to time with planned health use (example: pregnancy and childbirth) CRS-6

7 Adverse Selection Insurers Insurer practices to avoid/mitigate adverse selection Medical underwriting Coverage denial Exclusions for preexisting health conditions Rate ups Waiting periods Post-claims underwriting Cancelations Rescissions CRS-7

8 Insurance Market Segments Nongroup (individual) insurance market Group insurance market Small group: generally 2-50 employees (some states include groups of one ) Large group: at least 51 employees Buyers in individual and small group markets rely on producers CRS-8

9 Key Features of Group Coverage Plan sponsor Tax policy favors group coverage Bearing insurance risk State-licensed insurance carrier (fully-insured health plan) Employer or employee organization (self-insured/ selffunded health plan) CRS-9

10 Major Medical Insurance Comprehensive coverage Specific benefits vary Generally cover physician services, hospital care, prescription drugs, lab work, medical devices/supplies Mandated benefits, providers, covered persons vary by state, few federal requirements Cost-sharing requirements deductibles, copayments, coinsurance What it is not Limited benefit plans Long-term care Medicare supplemental CRS-10

11 Types of Major Medical Plans Indemnity Most flexibility in choice of providers Preferred provider organization (PPO) Largest enrollment share: 58%, 2010 Open networks; individuals pay more for non-network care Point of service plan (POS) HMO/PPO hybrid Health maintenance organization (HMO) Features to control utilization (e.g., limited networks, primary care provider (PCP), prior authorization) High-deductible health plan (HDHP) Certain HDHPs qualify to be paired with health savings accounts (HSA) CRS-11

12 Employment-Based Premiums Average Total Premiums, $16,000 $14,000 $12,000 $10,000 $8,000 $6,000 $4,000 $2,000 $0 $13,375 $13,770 $12,680 $11,480 $12,106 $10,880 $4,704 $4,824 $5,049 $4,242 $4,479 $4, Coverage for Family of Four Self-only Coverage Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2010 CRS-12

13 Nongroup Premiums Average Total Premiums, Selected Years $6,000 $5,568 $5,000 $4,442 $4,000 $3,000 $2,159 $3,329 $3,111 $2,531 $3,664 $2,835 $2,000 $1,665 $1,000 $ All policies Self-only policies Family policies Source: Medical Expenditure Panel Survey-Household Component, Agency for Healthcare Research and Quality CRS-13

14 Cost-sharing Cost-sharing requirements have increased Example: Average deductibles have increased across market segments and plan types Group HMO $401 $503 $699 Group PPO $461 $560 $634 Group HDHP $1,729 $1,812 $1,838 Nongroup self-only Nongroup family $1,972 $2,084 $2,326 $2,610 $2,760 $3,128 Sources: For group plans, Kaiser/HRET Survey of Employer-Sponsored Health Benefits, ; for nongroup policies, The Cost and Benefits of Individual and Family Health Insurance Plans, 2009, ehealthinsurance, December CRS-14

15 Out-of-pocket Spending Out-of-pocket (OOP) spending has increased Increase in OOP spending from previous year 8.6% 9.5% 10.5% 5.4% 6.6% Source: Milliman Inc., 2010 Milliman Medical Index, May 2010 CRS-15

16 Regulation of Private Coverage States State primary regulator Licensure Solvency Coverage Example: high risk pools Mandated benefits, providers, covered persons Example: dependent coverage Consumer protections Example: internal and external appeals Rating restrictions Restrictions vary by market segment Rate review Requirements vary by market segment CRS-16

17 Regulation of Private Coverage Federal Federal fallback enforcement PHSA (HHS) IRC (Treasury) ERISA (DoL) preemption Regulation of Employer-Sponsored Insurance (ESI) Fully-insured Self-insured ERISA State laws/regulations Share of covered workers (2010) 41% 59% Source: CRS, Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2010 CRS-17

18 Regulation of Private Coverage Federal Laws Example: COBRA continuation coverage Example: HIPAA Pre-existing conditions and portability Nondiscrimination Mandated benefits And then came PPACA CRS-18

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