Power to the Commissioner

The health care reform bill currently undergoing markup and debate in the House establishes a Health Benefits Advisory Committee, which will recommend covered benefits. The bill also establishes a “Health Choices Administration”, headed by a Commissioner. The duties of the Commissioner would be to establish and run a Health Insurance Exchange, establish and enforce health benefits plan standards, and other various functions. (pp. 41-3)

The Health Insurance Exchange would serve as command central, in control of the health plans offered by private insurance companies which choose to participate, as well as the public tax-payer funded plan. In order to be accepted by the Commissioner into this Exchange, the insurance company must agree to offer only one basic plan, only one enhanced plan, and only one premium plan. (The company may offer more than one premium-plus plan). (pp. 84-5)

The Commissioner will have authority to conduct audits of the health plans to make sure they are compliant with the Federal requirements and recoup the costs of these audits from the health plans they choose to audit. (p. 43)

The Commissioner (and Secretary of Health and Human Services) will limit the profitability of the qualified health benefits plans by specifying what the “medical loss ratio” (MLR) will be for the plans. The MLR is the amount of revenue from premiums that is spent to pay for medical services. (Most successful HMOs have a MLR of 0.70-0.80.) The bill establishes that plans will have to provide rebates to enrollees if their MLR is too low, i.e., their profit is too high. (p. 24, 54) [Capping profit … isn’t that what socialists do?]

The Commissioner “shall specify the benefits to be made available under Exchange-participating health benefits plans during each plan year . . .” (p. 84)

The Commissioner would determine to what extent health plans not being offered through the Health Insurance Exchange would have to comply with the requirements imposed on those plans which are being offered through the Health Insurance Exchange. (p. 40, lines 8-11)

A health plan must meet the following requirements in order to be classified as a Qualified Health Benefits Plan (QHBP):
- May not impose any pre-existing condition exclusions or otherwise limit coverage with respect to health status-related factors (p. 19)

- Must guarantee availability and renewability of health insurance coverage to (essentially) everyone (p. 20, 55)

- May not vary premium rates charged or any reasons other than age, area, or family enrollment (p. 21)

- May not discriminate in benefits regarding mental health and substance abuse (p. 23)

- Must meet Commissioner established standards in regard to provider networks (p. 24)

- Must adhere to Commissioner set limits on profit (dictated by medical loss ratio limits and required rebates paid by the insurance companies if not in compliance with the limits) (p. 24)

- Must provide coverage which includes payment for hospitalization, outpatient care, ER services, professional services from physicians and other health professionals, health equipment and supplies used in the delivery of care, prescription drugs, rehabilitative services, mental health and substance abuse services, preventative services, maternity care, well baby and well child care (pp. 27-8)

- May not charge cost-sharing fees for preventative services (p. 28)

- May not charge cost-sharing fees [co-pays] above $5000 for an individual and $10,000 for a family (in the first year) (p. 29)