HHS fi­nal­izes med­i­cal-loss ra­tio regs, re­jects in­surer re­quests

Modern Healthcare - - LATE NEWS -

HHS is­sued fi­nal reg­u­la­tions re­quir­ing in­sur­ance plans to spend min­i­mum per­cent­ages of premium dol­lars on pay­ing for health­care ser­vices this year or re­fund the dif­fer­ence to their cus­tomers next year. Un­der the med­i­cal-loss ra­tio pre­scribed by the Pa­tient Pro­tec­tion and Af­ford­able Care Act, new in­di­vid­ual and small group plans must spend 80% of premium dol­lars on med­i­cal care and health­care qual­ity im­prove­ment, with the re­main­der al­lowed for ad­min­is­tra­tive costs. The ra­tio for large­group plans is 85%. Karen Ig­nagni, pres­i­dent and CEO of Amer­ica’s Health In­sur­ance Plans, hailed changes to the pro­posed rule is­sued in De­cem­ber 2010 for rec­og­niz­ing some of the costs as­so­ci­ated with mod­ern­iz­ing the med­i­cal claims cod­ing sys­tem “as ac­tiv­i­ties that im­prove health­care qual­ity.” The fi­nal rule, how­ever, re­jected in­surer re­quests that the health ex­pen­di­tures side of the equa­tion in­clude all costs as­so­ci­ated with im­ple­ment­ing ICD-10 codes, as well as anti-fraud ef­forts. The rule also will wind down a “spe­cial cir­cum­stances ad­just­ment for mini-med plans,” giv­ing the cat­a­strophic in­sur­ance plans some lee­way in cal­cu­lat­ing their ra­tio un­til 2014. Con­sumers Union praised sev­eral com­po­nents of the rule but blasted that com­pro­mise. “To­day’s an­nounce­ment by HHS rec­og­nizes the need for mini-med plans to start in­creas­ing value for pol­i­cy­hold­ers by re­quir­ing them to phase-in the new MLR stan­dard,” Son­dra Roberto, staff at­tor­ney for the consumer ad­vo­cacy group, said in a state­ment. “But as long as these plans con­tinue, pol­i­cy­hold­ers may be left with un­ex­pected med­i­cal debt in the event of a ma­jor ill­ness.” in­clud­ing im­proved ser­vices for chron­icdis­ease man­age­ment. “In this new era of health­care, none of us can stand alone any­more,” Dr. James Kee­ton, Univer­sity of Mis­sis­sippi Med­i­cal Cen­ter’s vice chan­cel­lor for health af­fairs and dean of the school of medicine, said in the re­lease. Although the de­tails of af­fil­i­a­tion have not been de­cided on, one sce­nario would al­low UMMC and Health Man­age­ment As­so­ci­ates to work to­gether to boost in-hos­pi­tal ed­u­ca­tional and train­ing op­por­tu­ni­ties for physi­cians in the face of a loom­ing statewide short­age. “Do­ing so would en­hance UMMC’S abil­ity to grow the num­ber of physi­cians in Mis­sis­sippi, which lags be­hind nearly ev­ery other state in its per-capita sup­ply and dis­tri­bu­tion of doc­tors,” ac­cord­ing to the re­lease.

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