sA0 united states GeneralAccoun~oirice Wsshingcon, D.C. 20548 Health, Education and Ii- Semites Division Es-2m35 September2, 1997 The HonorableJamesM. JefEords c%aimq-eeonLabor and HumanResources United StatesSenate Subject: The Health InsurancePortabiliW and Accountabilitv Act of 1996: E&v Im&mentation Concems Dearlmchainnan The Health Insurance PoxtabBty and Accountab3iQ Act of 1996 (HIPAA) provides for, among other things, improved portability and contbuity of health insurancecomerageinprivate insurance markets and among employer sponsoredgroup health plans. At your Irequest we have been monitoring implementation of thesehealth coverage-relatedprovisions to identify any . emergingproblems. Many provisions of the act are already in force, wfiile others will soon becomeeffective. Carriers, employers, and state and federal regulators continue to develop approachesand me&anbns to impkment the act. Your Committeeis consideringholding a hearing on HIPAA implementation in the fbll to determine whether any emerging issues warrant considering changes to the regulations or kgi&tion. The committee also wants to know the extent to which market participants may be generating unintended consequencesin responseto the act For this reason,you asked for pr&mimry information on emergingHIPAAixnplementationissuesto &ame such a discus&n among market paxticipants. The issueswe identified reflect potential problems perceived by market participants during the early stagesof our field work performed between May and Juiy 1997. We did not try to validate speci& issues raised or determine the extent to which theseproblems actually exist. Discussions with federal agencies,state regulators, caniers, trade assodlions, and otheraSe&ed parties identified the following issuesas the most prominent or those w&h unintended consequent. (Seethe enclosurefor more detail on each of these issues.) GAOAEES9?-2OOB, Early EilPAA Implementation Concerns ._ . Health plan marketing practices and segregatedrisk pools may negativ&y affect accessand premiums for people e.h@blefor group to individual portability under HIP&I @IIF’& eligibles). - Guaranteerenewal requjrernents for some individuals may have negative consequencesfor consumers and caz&rs%ealth plans. - Someconsumersmay make poor choices on the basis of misconceptions ahout HPAA other issuesprimar@afFect Carrie&he&b plans: Reqtied . . certificates of creditable coverage may generate an admnustratipeburdenandmaybeunnecessazyinmostcases. - Full credit for high deductible and less comprehensiveplans may result in advexseselection. Still Other issues prima@ affect federal or state regulators: -’ &uestions remain about the ultimate regu&ory roles of federal and state agencies. Althou,@ all state altemative mechanism plans have been submitted and found acceptable,concerns about funding and accessremain. As impkmntaiion continues to unfol& we expect to identify more issues,and some current issues may cease to be of concern At the Committee’sinitial implementation hearjngs last February, much discussioninvolved the timing of sped&. - provisions and concerns about whether the Health Care Financing AdmmMWion, Department of Labor, and the w Department would be able to issue the initial regulations in a lamely fashion. They u&mately did so. Now the focus has shifted to clarifying and interpreting specific re@rements in the regdalions. In the near futurfz, different issues may emerge as state legislaturescontinue to modify state laws to comply with HIPAA and as insums and consumersmore fully confront the effects of the set on he&b insurancemarkets. GAO/EEES-97.2OOE Early HIP&L Imp&m!ntstion Concerns We sVilIrestrict distribution of this emrespondencefor 30 daysunlessyou request that we release it sooner. After that time, copieswill be made available on request. This hformation was developed under the guidance of Mi&ael Gutm&i, Assistat Director. Other xc@or contribtiors indude RandyINka and Betty Eirksey. Please calI me on (202) 5l2-4561or Mr. Gutowsld on (202) 512~7128 if you have any questions or comments on this letter or its enclosure. sincerely.yours, pc’rlliamJ. ScanIon Dire&or, Health F%nanchgand system-= 3 ENCLOSURE ENCLOSURE . EiARL4YIMPLEMENT Al-ION ISSUES___ AltiOugh HIPAA impiementation is still in its ear& stages,several issues have raised concem. Someissuesinvolve C~WUDEBmaking hnportant insurance de&ions on the basis of misconceptionsabout the accessprotettions available under EXIPAA-Other issuesrelate to carriers’ or health plans’ responses based on differing interpretations of state or federal regulations. still other ixnphnentation issuesrelate to possibleunintendedconseg~encesof the federal HIPAA regulations as written. On the basisof our prehthuy work, we identi&d the foIlowing mently cited early implementationissues as they relate to consumers, caniwtiti plans, and regulators. ISSUES TEAT PRlMARILY AFFECTCONSUMERS Carrier Marketing Practices and Segreateci Risk Pools Mav Neativelv Affect Access to and Cost of Coverwe Early evidence suggeststhat some HlPAA eligiblestrar&ioning from group to individual coveragemy have dB&iHy getting accessto products with port&Sty rights. Others may pay substantiallymore than the standard rate-for portability products. Moreover, certain carrier pricing strategies could result in even higher premiums for portability products in the future. The higher cost may be the result of cazziers’attemptsto segregateHIP&I eligibles from other market enrollees and prevent ~subsidization of premium rates. Some Carriers’ Marketing Practices Mav Hinder Accessto Portabilitv Products Some carr#ers’ practices may discourageHE?&3eligibles &om enrolling in portability products. In states we visited, consumershave complained to insurance regtibton that they were not t&d about carriers’ portability products or were told cars&s did not have such a product. In addition, some carriers have refused to pay colnmissionsto insuranceagentswho have referred HP&l eligibles to certain plans. Becauseconsumersoften use insurance agents to access the individual insurance market, an economicincenthe to steer individuals away from partability products could have a sign&ant impact. At least one state intends to challengethis practice under state fair marketing practice laws. Finally, carriers have also designedbenefit literature that may discourage individuals from applying for the portability product. For mple, one large national car&r pmvides consumersa one-pagesummary of its 4 GAOiEEHS97-2oOB Ear& HIPAA Imp~emexttation Concerns __ ~ENCLOSURE ENCLOSURE MPAA portability product that prominently features its benefit .- - limibtions and higher cost- H&her PremiumsEmerging for Portab2itv Products Remiums for someportability products may be substantialiy higher than for standard products. Ofthe Bve difkent carxiers whose rates we reviewed, only one chargedthe standardrate to BENA eligibles. The remainder charged or anticipated charging29,40,85, and 125percent above the stambd rate. To establish these rates, some carriers assumedthat the claims experience of HPAAe&ihleswouldbesimiktothatofind&idualsenrolledin ComprehensiveOmnibusBudgetReconciMion Act (COBRA) and other conversion products. One carrier basedits portability product premiums on the claims experience of state high-riskirsluance pools. In additiox&these are staudard rates that apply to generallyhealthy individuals. Except in the minority of states that do not permit carriers to medically underwrite in the irdividualmarke~ car&rsmaychargehi&erpremiumstoindividualsbecause they are unheaithy. -In addition to the initially higher rates, the way many carriers witt determini future premium rates for portabiMy products may lead to more rate increases Someprominent individuaI market car&s place HPAA eligibles into separate ratingpools,wherethe~highercl?lrrimscostscould~inhigher premiums. Moreover, some caniexspermit HIP& eligibles to apply for both the portability product and a lower cost standard product If individuals are healthy enough to passmedical underwriting, they become el@ble for and are thus likely to enroll in the standardproduct. If unhealthy, they are enrolled in the portability pW As one car&r official told us, this practice could result inanincreasing~ofpoorerIjsbisand~~p~~forthe~~~ pIWiW!tS. carrieroffi~toldusthatsegregatingHIpAA~l~aJxdcharginghigher premiumsisn~toprewentthe . .. remainder of the individual market from subs&mgHipAA~k,resut~inpremiumincreases. s. Regardiag permttbnghealthyHlPAAeligiblestoenroltinstandardproducts,acarrier official suggestedthat denyingthem the opportuni~&to enroll in a less expensh product would be unfair. HZPAAnever intended to address insurance costs, thus carriers must rate portaMity products fairly for all enrollees. 5 GAO/EEHS-9%2OOREarly HIPAA hnpiementation Concerns ENczosuRE Insuranceregulators point out that federal RIPAA regulations do not explicitly proMbit these rating practices in all instances. If a carrier ‘~chooses to offer HIPAA eligibles all of its individual market products or its two most popular products under the federal fallback approach, regtiWons do not explicitly require a risk-spreadingmechanism to subsidize the rates. Under the third federal fallback option, ca.rriersmay create new portability products but must include a risk-spreadingme&an&m or fbanciaI subsidization. Regulators suggest,however,that the lack of spe&city on what constitutes an acceptable risk-spreadingme&an&m will hamper state efforts to enforce this requirement. GuaranteeRenewalRc * ents Mav HaveNemth Conseauencesfor Consumersand Canie&Health Plans HCPAAregulationsexplicitly state the cir annstances under which an individual’s health coveragemay not be renewed or canceled The permissible cbmutances include nonpament of premiums and fraud. The onG&on of certain other permissible &cums&nces, however, may have negabive- consequencesfor consumersand carriers in the individual market. Three such circumstancesinclude individuals a$&iMg Medicare eligibilityage, Ming to. meet ageor income thresholds of certain targeted population insurance products, or physically or verbally abusing health care providers. RenewirwComurehm u for MedicareEMbles B&v Have NegativeCamemaces CarriersgeneId cancelindividnals’ comprehensive coverage when they become&@bie for Medicare. Req&ing carders to renew this coveragemay ham negativeimpkalions, accoTdingto s&te Wee regulator and carrier represent&Ives. FM, individuals risk losing their 6month open enrolhuent window for Medicaresupplemental Coverage. When individuals chooseto retain comprehensivecourage and therefore do not enroll in aMedicare supplement&product, they risk permanently losing the opportunity to obtain guaranteedaccessto Medicare supplemental coverage with no pnxsi&ing condition exclusions This could have -cant economic comences for consumersbecausethe comprehensive coverage may be more exgensh than the Medicaresupplementalcoverage. Because of the consequences,several state insurancereguhtors require carrim to notify enrollees of the implications of their choices. 6 GAO/HEHS97-2OOE Easly HIPS Ijmpiqmentation cOnCm3.s ENCLOSURE ENCLOSURE Second,carrier officWs told us they will need to change all current and future in*W market products to refiect the option of renewal at age 65. Con- wilheed to provide for coordinating benefits with Medicare and will need to be repriced accordingly. In many states, this wiu require carriers to file these changesand new products with the state insurance department Some states do not permit coordinalhg beneI%s. In these states,individuals may pay for expensivecoveragethat duplicates their Medicare benefits. Finally, a,ccor&g to the National Asocbtion of Insurance Cornmissloners@UK), renewing compreh~ coverage for those 65 and older could adverWy affect the individual insurance market Premiums for all individuals could increase as older and presumably less healthy individuals remaininthatmarket. insurance Promarm for Taxzeted Populations Mav Be Nes?alW%AfFected HIFVWsguarantee renewal reqgirement may also preclude carriers from canceIingcoverageunder targefed population insurance programs for individuals who exceed eli@biliQ guidelines, according to carzier representat&es. For exxnple, under certain subsidizedpublic and private insuranceprograms for low-income ind&iduals, carders might be precluded. from canceIing coverage once an enroUee*sincome exceedsthe eligibm threshold. Consequently, prom’ limited slots cotid be fiued by othm ineEgibleindmiduals Also, under childrenanly insurance produa, carriers could be forced to renew coverage for those who have reached adu&hood. G)uesbions Surround Whether Abusive Enrollees Mav Be Terminated -4-e insurance regulator told us that some carriers, particulariy health mab~tenanceorganization (HMO), are concernedthat the guaranteed renewal zmqdrement does not appear to permit the nonrenewal or canc4lation .of coveragefor those who physically or verbaUy abusehealth care providers. OneHMO official told us that such occurrences are common andthat carriers typically respond by tan&Ming coverage. Doing so now may violate H#?PAk consumersMavRaselmDoItant . . - Decmons on Misconce~ons Ahput EXIPAA Many consumersmay believe EIIPAA provides broader accessand protections thanitactwllydoes. Manyconsumershavecompla@edtostateinsurance regulators as a result of misunderstandbg their rights under HIPAA For example,some consumers believe they have gwmteedaccesstocoveragein 7 GAO/fIEHs-9702OOR Early HIpAt% ~~plemlltatioo Concerns ENCLOSURE ENCLOSURE the individual insurance market. This causesconcern when-a~~ individual waits until +dical care is necessarybefore applying for coverageonly to find coverage unavailable, according to one regulator. In addition, the regulator told us, individuals coming from group coveragehave waited beyond63 days to apply for individual coverage and thus have lost their portabiIity rights. Other consumers fail to understand that HIPA& requirementsdo not apply to group plans until the start of the next plan year. Therefore, an individual changing jobs and expecting portability may not get it, dependingon when the new employer’s plan year begins. Someregulators contend that the presshas poorly served the public by not acarately reporting on consumerprotections under - HIPM Another reguWor said much consumer eduwon remainsto be done. ISSUESTHAT PRIMARILY AFFECT CWrwPLANS issuance of Creditable Coveage Burden and Not Needed in Manv Instances The cost and admM&%W burden of issuing written certScates of crediW#e coverage for all enrollees terminating coveragewas one of the &st HIPM implementation issues to raise concans. Although ear& Mications suggest that caniers are generally complyirtg with the requhmen< concernsremain. Moreover, carrier representatives and insurance regulators continue to suggest that consumers will ultimately not need most certScates. Needed Certiiicate .Da& DBicult to Obtain and Cert&at es Costlv to Issue Some inform&ion needed to issue certiBcatesis proving difficult for carrim to obtain. Carriers ftequerttly cite that obtaining data on eachenroke’s dependents is troublesome. carriers and plan sponsorsare not always informed of changes in dependent status within families. Carriers contend that keeping records updated could be time consumingand expensive. Although HJPM provides carriers a transition period until July 1998to achievefull compliance, some carders still ham concerns about their abiB@to meet the deadline. Some carriers have also had di&ulty getting information on the me period between employee hire dates and the dates on which they becomeeligible to enroll in the health plan. Carriers hae not typically gotten these wa@ngperiod data from employers in the past and are now finding someemployersreluctant 8 GAOIEEHS-9702OOR Ear@ E3PM Iinpiesnenmtion Concerns ENCLOSURE ENCLOSURE or unable to provide it. In someinstances,the waiting period may vary among employeesand be consideredpart of the employeebene&spackages. As such, employersmay consider it cotidential and prefer not to routinely share it. Iri other cases,it may be acult to determinean employee’s wailing period. For example, quantifying the waiting period imposed on an individual who %quently enrolls and disenroUsin a health plan coinciding with his or her changhg part-thneKulHimestatuswould be difficult. Because of these problems, some carriers include a blanket statement on their certikates indicating that waiting period infoxmationmay be incomplete. In addition, carders have concernsabout their ability to issue a certificate for employeeswho have exhaustedtheir COBRAcoverage. Carriers must generally rely on employersfor this infoxmationand are concerned it may prove difficult or irnpossib~eto issue certEcates on a timely basis when employers do not provide the information in a timely manner. ~,canierssuggestthat~ecertificatesarecostlytoissueandmailto enrollees. About l-l/Z months into the certiSca$eissuauce reqWe~~ent, one large carrier had issuedabout 69,000notices and 6,000 cerMicates cost&g about -000. Another large car&r was solicited by a benef& consulting prm to handle the cerEcation process. The Grm proposed charging the car&r $7 for each of the approximately 140,000retroactive cerfifi~ to be issued and thereafter -. 19 cents per enrollee per month for ongoing certScation -on. Although the car&r had the capabili@ to m the cerUfical3onprocessinternally, somesmaller caniers and employers may not and could face similar costs. QuestionsPersist About c&i&ate Some skte insurance re@ators, carders, and health plan admi&&&ors continue to question the applicabilhy of the at&ate issuance reqirement whenenrolkesswitchhealthplansduringanopenenro~entperlod. For example,representativesof one state employeebeneiits plan said they face an upcoming open enrollment period and are still uncertain about whether certiBcatesmust be issued. They said that much confusion would be created if a certScate must be issuedto eachenrollee who switches plans. Insurance regulatory in that state expressedsimilar concfxns. During an educational seminar for employerssponsoredby the Depaztmentof Labor, Questionsabout certi&ateissuanceduzingopenenrollmentperiods were commor~ 9 GAO/EEES-9%ZOOBEarly HIPM Implementation Concerns ENCLOSURE ENCLOSURE These Questions persist even though federal regulations do not expkitiy require cert@cates to be issuedin theseinstances. The regulationskquire instead &at issuerSprovide enoughinform&on to the new issuer or the plan -or to ensure that any subsequentcer@cate accurately reflects the prior coverage. OBcials from one large carrier, however,pointed out that they usually have no way of knowing if individuals are switching to another plan or are disenrol3ing altogether. They only receivenotiEcation that the individual has dropped coverageand they must therefore issue a certificate. Offici& noted tha2 these certU%cates are not needed,raise questionsand concerns for enrollees, and cost money to issue and send. (%stificateIssuance~ent MavCreate Additional Administrative Burden for State Medicaid Agencies state and NAIC offic3alssuggestthat becauseof characteristics of state Medicaid programs and the Medicaid population, cerWcate issuance will pose an additional adlministratmeburden for state Medicaid agencies. Some Medicaid recipients tend to enroll and d&enroll in the program as income and emploment status changes. Issuing certificates in each instance witl increase the vohune of certificates issued. Also, accordingto NAIC, Medi&d agenci~ have a dSkult time maWaWng accurateaddressesfor enrollees and would expect a large volume of ceztikates to be retumed as undeliver&le. Carrier representaWeshavelong contendedthat certificates would not be necessaryto prove c&&able coveragein most cases. NMC and carrier representativespoint out that small group port&%* refosms in place in most states have succeededwithout certi&caIion req@emenls Where proof of prior coveragehas been needed,carriers m shnply c&d the prior carrier or requestedthe enrollee to furnish document&on. In addilion, many carriers do not include pre+xMng comBion clausesin group market products and therefore will not need certEcates from incoming enrolkes. Ofkials &om one large carrier we vi&ted told us they have dropped the clauses for most products becauseofthedifEcn@ofadnairristeringth~underHTpAk To quantify the extent to whkh consumersmight actually need the certificate to obtain coverage,three carriers cited the low number of certiIic!ates early disenrollees have reqaested. On the June l,l!B7, efkctke date foI certEcate issuance, HIP&i repaired carriers and plan Vors to provide either actual cerMcates or notices of certikate eIigibiliQ for all &senrolkXS 10 GAOIHEES-9%2OOBEarly HlpM Implementation Concerns ENCLOSURE EMx4osuRE retroaCtiYeto October 1,1996. Three caniers we visited sent notices instead of certB+zs. The notices generally informed disenrolks that-they were entitled to and-could obtain a cerliiicate upon request. Thesecarriersbad very low request rates estimated at 13,2, and 3 percent. One official said that had d&enrollees actual@ needed the cxxtificates to prove creditablecoverage,the canier would m had many more requests. Another car&r official suggested that many c~cates that consume requestedwere probably not neededbut requested out of ignorance or caution The Blue CrossBlue Shield Association, ti its comments on HPAA regulations, &mates that up to 90 percent of individualslosing cowrage will not need certificates issuedto prove creditable coverage. Full Credit for High . Deductible and ComDrefiensve Plan.. Mav Cre.a@ O~~~rtunifies for Adm. Selection HIPAAregulations~thatahedlthplangmefutlcreditforabroadrange of prior coverageregardless of the deductible level of that coverage. Carriers and insurance regulaku~ are concerned that this provides an oppor&nity for gaming. That is, an individual could maMain a high deductibleplan while . healthy and then switch to comprehensive,low deductible coveragewhen medical needs arise. Likewise, a sntaUemployer could switch the entire group plan from a high to a low deductible plan once an employeebecomesill. An ~~idualcouldlikewiseswitchfromaplanwithminimalbenefitstoonewith more comprehensive coverage once additional coveragewould be necesary. The resulting adverse selection against low deductible, comprehensiveplans could result in higher rates for those plans. Moreover,carriers could limit the bentits available undef low deductible plans to lessenadverseselection. . ocatlcm of Enforcement AuthontV* Federal and State Agencies Not Yet Resolved The ovmlght and enforcement roles of federal and state agencieshavenot yet beenfullydetezmined. ~statecompliancewithHIP&Utaynotbefully determined until 1998 or beyond. Although HEWi has req@redstatesto report toHcFAon~~mechanisnplans,statesarenototherwiserequiredto report on compliance activ&ies or status. To determine whether all stateshave enacted laws or regulations that comply with IIEAA, HWA wilt have to review publicly available data sources and may, according to HCF’Aofficials, haveto 11 GAOhiEHS-9702OOR Early ElPAA Implementation Coneems ENCLOSURE ENCLOSURE visit each state individually. HCFA officials said that this review could take at lea&l Year. If HCF’Adetermines that certain HIPAA provisions havenot been incorporated into-s&atelegislation or regulations or that states are not substantially enforcing these provisions, HCFA will have to enforce the provisions. Early evidence suggeststhat some states Ml not addressall EXIPAArequirementsor will not dosoinatimelymanner. OneofthreestateswevMtedwasnotEkelyto include aRproMsions of HIP& in its statutes before 1998. A regulator there Mkated that in the interhn, HCFAmay have to enforce those provisions. In addition, HCF’A officials have heard anecdotal reports about severalother states possibly not inchujing certain HIPAA provisions in their statutes. Finally, HCFA is expected to be the primary enforcementau&o&y for all HIPAA provisions in at least two states and two U.S.territories On the bash of its review of state laws, HCFA could determine that it will have the prhnazy enforcement authoriQG,n additional states. State Altematim Mechanisn Plans Found Accentable. but Some Concerns F&?main Thirty-nine staWs and the Distzict of Calm have notified HCFA of their intention to implement altemative mechnisms to implement HlPfWs group to individual portability mquirements. Thesemecha&ms generally must be effkctive as of January 1,1998. After a preliminary review, HCE’Afound all states’ plans acceptable but recognizesthat uliimateQ determining compliance and effectiveness will not take place before 1998or beyond. Meanwhile,some concern has emerged about the possible effect on those not eligible under HP&L Twenty-twg of the thirQ&ne state &em&ve me&anisu will use a bigkisk pool to provide group to individual portabUty. Past apexience with state high- riskpoolprogramssuggeststhatfundinglimitationscanresultincapped enrollment or waiting Bsts. Becausefederal regulations will requke that HIPAA eligibles not have to wa& for coverage,concerns esist that accessto high-risk pools for those not eligible under HIPAA could be further reduced. HCFA officials note that should this occur, HCF’Acould not disapprovethe akrnath mechanisms. Onlyifa~waitlistedHIPAA~~l~oro~~d~~ coverage could HCFA recpdrea state to changeits aknati~ mechanisn. (101561) 12 GAO/HEHS-97-2008 Early HIPAA In@emen~on Concerns Ordering Information The first copy of each GAO report and testimony is free. Additional copies are $2 each. 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The Health Insurance Portability and Accountability Act of 1996: Early Implementation Concerns
Published by the Government Accountability Office on 1997-09-02.
Below is a raw (and likely hideous) rendition of the original report. (PDF)