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)

sA0    united states
       Wsshingcon, D.C. 20548

       Health, Education   and Ii-   Semites Division

      September2, 1997
      The HonorableJamesM. JefEords
       and HumanResources
      United StatesSenate
      Subject: The Health InsurancePortabiliW and Accountabilitv Act of 1996:
      E&v Im&mentation Concems
      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

      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:
              . . certificates of creditable coverage may generate an
-          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

           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

                   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
you have any questions or comments on this letter or its enclosure.


pc’rlliamJ. ScanIon
Dire&or, Health F%nanchgand

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.
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
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
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
      . ..                             remainder of the individual market from
       s.                                                     Regardiag
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

5            GAO/EEHS-9%2OOREarly HIPAA hnpiementation                  Concerns
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
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.
             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
   . .                      -
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.

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
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.

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
     -.    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

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
Full Credit for High
                  .  Deductible and
     ComDrefiensve Plan.. Mav Cre.a@
O~~~rtunifies for Adm. Selection

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
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
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
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-
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.


12           GAO/HEHS-97-2008         Early HIPAA In@emen~on           Concerns
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