Sec.113 INSURANCE RATING RULES
a) allows for limited variations in rates QHBPs charge enrollees
b)1) requires a study of large groups, self-insured employers vs. those with a bought plan, including solvency issues for the self-insured.
b)2) requires a report on this study to with recommendations to make sure that there are no incentives for smaller employers to self-insure, or which will "create adverse selection in risk polls of large group insureres of self insured employers". Is this adverse selection adverse to the insurers or the insured?
Sec. 114 Nondiscrimination in benefits.
a) To understand this properly you have to look us sec 702 ERISA 1974, Sec 2702 Public Health Services Act, and Sec 9802 of the Internal Revenue Code of 1986. Which I haven't got to yet.
b) requires parity in mental health and substance abuse benefits, making the provisions of Sec 2705 of the PHSA applicable to all plans, both individual and group, as long as they are not superceded by or inconsistent with Subtitle C.
Sec. 115 ENSURING ADEQUACY OF PRIVIDER NETWORKS.
a) QHBPS areto have enough profiders in their networks that their enrollees can actually get the covered services. What happens if no QHBPs in a geographic area can get enough folks to accept their plans?
Transparency in the cost-share differential between in network and out-of-network is required. Every plan I've ever had had this in the enrollment book and printed on the insurance cards.
Sec. 116 ENSURING VALUE AND LOW PREMIUMS
a) seems to basically mean that if a QHBP takesi n more than a pre-set % of what it pays out it must rebate the excess to enrolees. The term medical loss ratio is used, which seems to mean the portion of premiums taken in that is used to cover enrollees claims.
b) the Commissioner is to use HHS methodology to set the MLR. It must be high enough to get insurers to participate. Though if the MLR is what they pay out, it would seem that they mean setting the percentage of premiums NOT spent on enrollee claims high enough.
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