BILL ANALYSIS
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|SENATE RULES COMMITTEE | SB 316|
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THIRD READING
Bill No: SB 316
Author: Alquist (D)
Amended: 12/17/09
Vote: 21
SENATE HEALTH COMMITTEE : 6-4, 4/1/09
AYES: Alquist, Cedillo, DeSaulnier, Leno, Pavley, Wolk
NOES: Strickland, Aanestad, Cox, Maldonado
NO VOTE RECORDED: Negrete McLeod
SENATE APPROPRIATIONS COMMITTEE : 7-5, 5/28/09
AYES: Kehoe, Corbett, DeSaulnier, Hancock, Leno, Oropeza,
Yee
NOES: Cox, Denham, Runner, Walters, Wyland
NO VOTE RECORDED: Wolk
SUBJECT : Health care coverage: disclosures
SOURCE : Author
DIGEST : The bill broadens an existing statutory
disclosure requirement that health plans and insurers must
meet. That existing disclosure provision requires plans,
insurers, their employees or their agents to disclose in
writing the medical loss ratio for the previous calendar
year when presenting a plan for examination or sale to any
individual or group consisting of 25 or fewer individuals.
Under this bill, this disclosure provision will be expanded
to individuals and groups consisting of 50 or fewer
individuals.
CONTINUED
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Senate Floor Amendments of 12/17/09 delete a requirement
that health plans and insurers have a "medical Loss ration"
(a requirement that health plans spend a minimum percentage
of premiums on health care services) of 85 percent, and
broaden an existing medical loss ration disclosure
requirement that currently applies to individuals and
groups of 25 or fewer individuals, to instead apply to
individuals and groups of 50 or fewer individuals.
ANALYSIS : Existing law provides for the regulation of
health care service plans (health plans) by the Department
of Managed Health Care (DMHC) and regulation of disability
insurers who sell health insurance (health insurers) by the
Department of Insurance (DOI).
Existing law requires health care service plans to submit
for review and approval all of the types of plan contracts
they offer. Existing regulations provide that the
definition of administrative costs shall take into
consideration such factors as the plan's stage of
development, and provides that, if administrative costs
exceed a certain percentage (15 percent for established
plans and 25 percent for plans in the development stage),
the plan may be required to justify administrative costs
and/or show that it is taking effective action to reduce
administrative costs.
Existing regulations pertaining to health plans provide
that "administrative costs" include only those costs which
arise out of the operation of the plan, including salaries,
bonuses and benefits paid, the cost of soliciting and
enrolling subscribers and enrollees, the cost of processing
and paying claims of providers and of claims for
reimbursement by subscribers and enrollees, legal and
accounting fees and expenses, and costs associated with the
establishment and maintenance of agreements with providers
of health care services enrollees.
Existing regulations define a standard of "reasonableness,"
for the ratio of medical benefits to the premium charged
for individual health insurance, and sets this ratio at 70
percent.
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Existing law also gives the Commissioner authority to
disapprove individual health insurance policies that
provide no economic benefit to the consumer.
Existing law requires that Medicare supplement policies
sold by health plans and health insurers return to
enrollees a minimum percentage of the aggregate amount of
premiums earned (75 percent for group policies and 65
percent for individual policies).
Existing law requires health plans and health insurers to
disclose in writing the ratio of premium costs to health
services paid for plan contracts with individuals and with
groups of the same or similar size for the plan's preceding
fiscal year when presenting a plan for sale to any
individual purchaser, or a group consisting of 25 or fewer
individuals.
The bill broadens an existing statutory disclosure
requirement that health plans and insurers must meet. That
existing disclosure provision requires plans, insurers,
their employees or their agents to disclose in writing the
medical loss ratio for the previous calendar year when
presenting a plan for examination or sale to any individual
or group consisting of 25 or fewer individuals. Under this
bill, this disclosure provision will be expanded to
individuals and groups consisting of 50 or fewer
individuals.
Background
Medical loss ratio . The amount of money that a health plan
or health insurer spends on medical care, versus
administrative expenses and profit, is referred to in the
health care industry as a medical loss ratio, or a minimum
loss ratio.
California law does not prescribe specific medical loss
ratio requirements per se, with the exception of individual
health insurance policies. The DOI sets a standard of
"reasonableness" for the ratio of medical benefits to the
premium charged for individual health insurance at 70
percent for new policy forms submitted after July 1, 2007,
and for existing policy forms that file rate increases.
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(The reasonableness standard for existing policy forms,
that do not file a rate increase, is 50 percent, which was
the standard of reasonableness set in 1962.)
Health plans regulated under DMHC are required by
regulation to hold administrative costs, as defined, to 15
percent of premiums, with certain exceptions. This leaves
the amount spent on medical care at the discretion of the
plan, provided this limit is maintained. Health plans have
been held to this standard since 1975.
While "medical loss ratio" appears to be a straightforward
term, there are several ways it is applied. DOI uses
"lifetime anticipated loss ratio," an actuarial method that
recognizes that the loss experience of policies,
particularly individual health policies that undergo
medical underwriting, changes over the life span of the
policy. According to guidance from DOI, the medical
expenses in a new policy would be expected to be low in the
first few years, because subscribers are subject to
underwriting that is designed to eliminate those likely to
generate a large number of claims. As a consequence, in the
early years, the loss ratio might be lower than 70 percent.
But as the predictive force of medical underwriting
declines over time, the benefits paid out typically
increase, so that the loss ratio in later years could
exceed 70 percent. The lifetime anticipated loss ratio
used by DOI takes this "durational effect" into account
and, in combination with other factors, combines the low
and high loss ratio years so that the overall loss ratio
during the anticipated life span of the insurance product
will meet the 70 percent target, even if it dips below the
target in a particular year.
Another way to apply a medical loss ratio is by averaging
total costs across all contracts or policies offered by a
health plan or health insurer. Additionally, what counts
as a medical expense can be broadly construed to include
programs or services that aim to improve patient care and
outcomes, such as disease management programs, health
information technology, wellness programs and
pay-for-performance programs.
FISCAL EFFECT : Appropriation: No Fiscal Com.: Yes
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Local: Yes
According to the Senate Appropriations Committee (previous
version of bill):
Fiscal Impact (in thousands)
Major Provisions 2009-10 2010-11
2011-12 Fund
DOI Regulations $227 Special*
DMHC Regulations $90-$167 $180-$333Special**
DOI oversight $529 $1,058$1,058Special**
& evaluation
DMHC oversight $90-$200
$180-$400Special**
& evaluation
* Insurance Fund
**Managed Care Fund
SUPPORT : (Verified 1/26/10)
California Teachers Association
CTW:do 1/26/10 Senate Floor Analyses
SUPPORT/OPPOSITION: SEE ABOVE
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