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1 M d c L o R oru : E n ur ngv uf org or g H t hc r Con um r I ubr f S pt mb r2011 Pr p r dbyg or g W t c h ndg or g nf orh t hyf ut ur

2 Mdc Lo Rto: Enurng Vu for Gorg Hth Cr Conumr w wrttn by: Hoy Lng Cndy Zdn Hth Acc Progrm Drctor Excutv Drctor Gorg Wtch Gorgn for Hthy Futur 55 Mrtt St. NW, Sut Edgwood Av. NE, Sut 815 Atnt, GA Atnt, GA (404) (404) hng@gorgwtch.org czdn@hthyfuturg.org Gorgn for Hthy Futur (GHF) nonproft hth pocy nd dvoccy orgnzton tht provd voc for Gorg conumr on vt nd tmy u. GHF pproch t go of nurng cc to quty ffordb cr for Gorgn n thr mjor wy: 1) outrch nd pubc ducton, 2) budng mngng nd mobzng coton nd 3) pubc pocy dvoccy. A progrm of nonproft conumr dvoccy orgnzton Gorg Wtch, th Gorg Hth Acc Progrm brodn ccbty to f, ffordb nd ffctv cr for vunrb Gorgn by promotng pro- conumr tt v rguton nd orgnzton poc, fotrng conumr mpowrmnt through ducton nd outrch, nd nggng ky tkhodr n prtnrhp mnt to boot communty hth. Both Gorg Wtch nd Gorgn for Hthy Futur r fundd n prt by th Hthcr Gorg Foundton. Crtd n 1999 n ndpndnt, prvt foundton, th Foundton mon to dvnc th hth of Gorgn nd to xpnd cc to ffordb, quty hth cr for undrrvd ndvdu nd communt.

3 In rcnt yr, Gorg conumr hv n thr hth nurnc prmum kyrockt wth fw rourc to mur how thr prmum dor r ctuy pnt or wht rprnt good vu n n nurnc pocy. For xmp, how much of ch prmum dor ctuy go towrd hth cr nd how much go towrd nurnc compny xpn k mrktng or compny proft? Th ck of nformton h md t dffcut for conumr to choo pn bd on vu nd ow om nurr to offr ow-vu, nfror product tht my not provd uffcnt cc to quty cr. A nw provon of th Ptnt Protcton nd Affordb Cr Act known mdc o rto (MLR) ddr th probm nd provd grtr vu for conumr by rqurng nurnc compn to not ony dco how thy pnd thr pocyhodr prmum dor but o ddct t t 80 prcnt of tho pd prmum dor to drct mdc cr nd quty mprovmnt progrm for thr cutomr. If n nurnc compny f to ht th mrk, t w hv to provd rbt to t conumr to mk up for th hortf. Th tndrd dd much ndd do of trnprncy to th hth nurnc mrktpc nd hod nurnc compn ccountb for nurng tht ptnt rcv th mdc cr thy hv pd for nd drv. Gorg nurnc commonr, howvr, rqutng nncy on bhf of Gorg nurnc compn to ph n th provon ovr thr yr rthr thn mpmnt t mmdty. In th brf, w xpn how th nw MLR ru w bnft Gorg conumr nd why our pocymkr houd mk vry ffort to mpmnt thm qucky pob. 2 P g

4 Wht Mdc Lo Rto (MLR)? An MLR th prcntg of prmum tht nurnc compn pnd on mdc cr for thr cutomr. Inurnc compn n Gorg hv not htorcy bn rqurd to pnd t mount of prmum dor on ctu mdc rvc on bhf of thr cutomr. Undr th nw ru, nurnc compn ng ndvdu pn mut pnd t t 80 prcnt of th prmum thr cutomr py on mdc cr nd quty mprovmnt ctvt. Inurnc compn r fr to pnd th rmnng 20 prcnt on mrktng, proft, or othr dmntrtv functon. Tx nd f r not ncudd n th quton. If nurnc compn f to mt th tndrd, thy mut provd cutomr rbt. Yr ftr yr, Gorg conumr hv wtchd thr hth nurnc prmum ncr mor qucky thn thr ncom but hvn t hd cc to th nformton ncry to choo th nurnc pn tht provd th mot bng for thr buck. How th MLR ru w bnft Gorg nurnc conumr Strtng n 2012, nurnc compn oprtng n Gorg ndvdu mrkt mut mt th 80 prcnt trgt or provd rbt to thr cutomr. If th nw rqurmnt wr mpmntd tody, th nurnc compn woud hv to rbt th nry 350,000 Gorg cutomr nrod n thr hth pn tot of bout $42.6 mon, or tt mor thn $100 pr cutomr, on vrg. If th djutmnt grntd, th tot mount rbtd woud drop to bout $8.4 mon. It o mportnt to kp n mnd tht th go bhnd th ru to provd n ncntv for nurnc compn to oprt mor ffcnty nd to u cutomr prmum dor wy. If thy cnnot mt th ronb tndrd by mprovng thr oprton, thn conumr houdn t hv to wt mony on ow-quty, nffcnt product. Intd, conumr houd b b to mk n nformd purchng dcon bd on vu. Impmntng th MLR ru n Gorg In Gorg, 19 nurnc compn r cnd to ndvdu hth poc. Th compn rng from m rgon compn to rgr nton ntt. Th tt rgt nurnc compny for ndvdu pocyhodr Bu Cro Bu Shd of Gorg, wth bout 173,000 pocyhodr throughout th tt. Th Gorg Offc of Inurnc nd Fr Sfty Commonr cn nd rgut nurnc compn n Gorg. Addtony, th offc ntrct wth th fdr govrnmnt on mny rgutory u, ncudng nw provon uch th MLR ru. Wh th nurnc commonr h not htorcy rportd nformton on th MLR of Gorg nurnc compn, thy gthrd th nformton nd md t pubcy vb for thr djutmnt rqut to th Dprtmnt of Hth nd Humn Srvc (HHS). Howvr, th nm of th nurnc compn hv bn rmovd, nd w r not b to mtch prtcur nurnc compny wth t MLR. In 2009, th nurnc compny wth th rgt mrkt hr of Gorg hd n tmtd MLR of 77.65, whch fry co to th 80 prcnt tndrd. St, for vry prmum dor tht cutomr 3 P g

5 pd, mor thn ffth w pnt on omthng othr thn ptnt cr. Svr othr nurnc compn n Gorg hv MLR tht r condrby owr, whch ndct th mjorty of th nurnc compn n Gorg coud oprt mor ffcnty thn thy r now. Bow chrt of th tmtd rbt 19 Gorg nurnc compn woud provd to conumr f thy do not ncr thr rto undr th 80 prcnt tndrd nd th rbt thy woud provd to conumr f thy do not ncr thr rto but oprt undr th tndrd propod n th djutmnt ppcton. Th rbt fgur td bow wr provdd by th Offc of Inurnc nd Fr Sfty Commonr, nd r ggrgtd for th yr 2011, 2012 nd 2013 bcu tht th prod for whch th nurnc commonr offc rqutng n djutmnt. $45,000,000 $40,000,000 $35,000,000 $30,000,000 $25,000,000 $20,000,000 $15,000,000 $10,000,000 $5,000,000 $- Etmtd rbt to conumr undr currnt MLR ru Etmtd rbt to conumr f Gorg grntd n djutmnt to MLR ru Gorg MLR djutmnt rqut Th MLR ru w dvopd ftr thorough nd thoughtfu proc hdd by th Nton Aocton of Inurnc Commonr tht condrd wth of nformton from nurnc compn, nurnc rgutor nd conumr. To nur tht th ru chv thr go, th HHS but n vr xcpton to protct conumr nrod n pn offrd by mr nurnc compn who my xprnc mor vrton n how thy pnd prmum dor from yr to yr. Inurnc compn wth thn 1,000 nro r xmptd ntry from th rqurmnt nd nurnc compn wth up to 75,000 nro rcv crdbty djutmnt, ffctvy owrng th trgt MLR thy mut mt. In mot c, th xcpton houd b uffcnt to protct conumr. 4 P g

6 Tht d, f thr vdnc tht mmdt mpmntton of th ru woud dtbz th mrkt nd rut n fwr choc for conumr, tt cn ppy for n djutmnt to th ru for up to thr yr. Gorg h md uch rqut, whch currnty undr condrton by th HHS. If thr concrt vdnc tht nurnc compn w xt th tt nd v conumr unnurd, om ort of djutmnt my b wrrntd. Howvr, Gorg ppcton ndct tht no nurnc compn hv provdd form notc tht thy w xt th tt. Inurnc compn my wnt n djutmnt bcu thy r concrnd t my t nto thr proft but tht do not mn tht uch n djutmnt good d for conumr or tht tho nurnc compn cnnot tr thr bun mod to compy wth th nw rqurmnt. Concuon nd rcommndton For Gorg conumr wthout mpoyr-ponord hth nurnc, purchng ndvdu hth nurnc cn y prov prcy nd confung. Th nw MLR ru r dgnd to pur nurr not ony to b mor trnprnt n thr pndng but to o nur conumr gt th mot vu for thr prmum dor. Gorg nurnc compn houd mk vry ffort to mt th nw rqurmnt, nd th nurnc commonr houd mk vry ffort to ncourg thm to mt t qucky pob nd nforc t vgorouy. If nurnc compn offrng ow-vu, poor quty pn to conumr don t mt th tndrd, thy houd b rqurd to rbt thr pocyhodr, nd not rcv fr p. On bhf of Gorg conumr, w urg th HHS to drct Gorg to mov wfty pob to provd fnnc rf nd vu to our tt hrd workng conumr by mpmntng th nw MLR ru. Wh m porton of prmum dor r pnt on govrnmnt cot, uch fdr nd tt tx, rgutory nd cnng f, th cot r not ncudd n th mdc o rto ccuton. 5 P g

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