Health Care Reform

Government regulation and oversight

Like many business sectors, health insurers are subject to state regulations that govern their operations, and each state has its own set of rules. States typically oversee individual and small group premium rates, establishing a rate review process and seeing that process is met. They typically require detailed documentation to support and explain changes in rates, including data about medical claims and administrative costs. Additionally, insurers are required to explain how premium dollars are spent and document that they are financially sound and able to meet claims for payment.

As with most documents required by government agencies, rate and/or financial filings are a matter of public record, depending on the laws of each state.

State regulations

Idaho

The Idaho Insurance Department has extensive rules governing insurers, covering such issues as:

  • appeals and external review of claims denials
  • description of each type of policy offered
  • determining what services are covered (mandates)

 

Oregon

This "Common questions" list gives a brief overview of the breadth of Oregon's oversight of health insurers for such issues as:

  • timely claims payment
  • appeals and external review of claims denials
  • guaranteed renewability of policy
  • description of each type of policy offered
  • review of advertisements and materials describing policies
  • determining what benefits are offered (mandates)
  • review of medical utilization by members

"Health Insurance In Oregon" is a comprehensive look at the state's top seven health plans and their finances.

 

Utah

The state insurance department has oversight of such health insurer functions as:

  • appeals and external review of claims denials
  • description of each type of policy offered
  • determining what benefits are offered (mandates)

 

Washington

Washington has a "Patient's Bill of Rights" that addresses many insurance company practices, including:

Washington helps consumers compare the efficiency and financial condition of health plans.

Also, Washington State requires that private insurers accept 92 percent of individual applicants (those seeking non-employer based coverage), and assesses a levy on health plans to fund a high-risk pool for persons who cannot qualify for private coverage.

 



Federal regulation

Almost half of the national health expenditure, expected to near $3 trillion in 2011, is spent through federal programs covering about one in three Americans. These are administered by private sector health insurers, like Regence, according to the rules of each agency:

  • Centers for Medicare and Medicaid (CMS) sets rules for these programs, along with SCHIP (children's health)
  • The Department of Defense makes rules for Tri-Care, which covers military families
  • Department of Labor oversees ERISA and COBRA rights under employer-offered health plans
  • The Department of Health and Human Services oversees how the health care system, including insurers, implement the Health Insurance Portability and Accountability Act (HIPAA)

Numerous federal agencies will be involved in setting rules to implement the Patient Protection and Affordability Act, passed by Congress on March 23, 2010.


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