National Association Of Insurance Commissioners Research Articles

Medical care services interplay between individual and Medicaid managed care markets in expansion versus non‐expansion states

AbstractWe study enrollment, medical service utilization, and incurred expenses of individual comprehensive and Medicaid managed care plans in states with or without Medicaid expansion adopted at the Affordable Care Act (ACA) early stage 2014–2016. To make healthcare services more accessible, 27 states expanded Medicaid eligibility to cover nearly‐poor non‐elderly adults who have had incomes between 100% and 138% of federal poverty level in 2014. In non‐expansion states, early enrollees in this income cohort had to choose individual market plans rather than Medicaid. Early enrollees' enrollment choices and their health status have had a great impact on the individual market premiums and Medicaid spending. We examined health insurers' annual regulatory filings with the National Association of Insurance Commissioners for 2013–2016 and found that: First, individual comprehensive insurance enrollment grew much faster in states not expanding Medicaid eligibility. Second, after incorporating early enrollees, per member per month (PMPM) medical service utilization and expenses of individual comprehensive insurance grew much faster in non‐expansion states. Third, among major types of medical utilization and expense measures, PMPM hospital inpatient days and PMPM prescription drug expenses increased substantially since 2014. Finally, Medicaid beneficiaries generated more PMPM medical utilization and expenses in expansion states.

The market for model laws: The diffusion of NAIC model laws

AbstractThe National Association of Insurance Commissioners (NAIC) issues model laws to promote uniformity in the US state‐based insurance regulatory system. In this paper, we study the diffusion of 197 NAIC model laws, examining the adoption patterns and influencing factors. Employing a network algorithm, we uncover the underlying network over which model laws spread. The NAIC plays a central role in this network, and its influence increases over time. Additionally, we explore factors affecting states' model law adoptions from three perspectives: the laws' attributes, the states' internal characteristics, and external influences. We find that a law's attributes play a key role. Model laws characterized by low complexity, distinct from existing state laws, mandated for accreditation compliance, and recently amended are more likely to be adopted. While we do not find significant impacts of various state‐internal characteristics, our results reveal that states follow geographic and ideological neighbors in adopting model laws.

Claim Reserves Estimation Using Chain Ladder Method in Casualty Insurance for the Period 2010 - 2019

In a work environment, the presence of risk or unforeseeable events is inevitable, as employees certainly seek to get a sense of security in doing work. Therefore, insurance is responsibility to provide sense of security to employees by providing protection in the form of claim payments to employees who get accidents. To meet the claim payment, insurance companies need to prepare funds. With the chain ladder method, insurance companies can estimate how much funds must be prepared to make claim payments. This study used the secondary data from general insurance companies in the United States published by the National Association of Insurance Commissioners under the title "Statistical Compilation of Annual Statement Information for Property/Casualty Insurance Companies in 2019". Data in the form of cumulative run-off triangle with accident period 2010-2019. Through this calculation, claim reserves that must be prepared by insurance companies for 2020 amounted to USD 1,553,906.

Medical cannabis laws lower individual market health insurance premiums.

To evaluate the impact of medical cannabis laws (MCLs) on health insurance premiums. We study whether cannabis legalization significantly impacts aggregate health insurer premiums in the individual market. Increases in utilization could have spillover effects to patients in the form of higher health insurance premiums. We use 2010-2021 state-level U.S. private health insurer financial data from the National Association of Insurance Commissioners. We examined changes to individual market health insurance premiums after the implementation of medical cannabis laws. We employed a robust difference-in-differences estimator that accounted for variation in policy timing to exploit temporal and geographic variation in state-level medical cannabis legalization. Seven years after the implementation of Medical Cannabis laws, we observe lower health insurer premiums in the individual market. Starting seven years post-MCL implementation, we find a reduction of $-1662.7 (95% confidence interval [CI -2650.1, -605.7]) for states which implemented MCLs compared to the control group, a reduction of -$1541.8 (95% confidence interval [CI 2602.1, -481.4]) in year 8, and a reduction of $-1625.8, (95% confidence interval [CI -2694.2, -557.5]) in year 9. Due to the nature of insurance pooling and community rating, these savings are appreciated by cannabis users and non-users alike in states that have implemented MCLs. The implementation of MCLs lowers individual-market health insurance premiums. Health insurance spending, including premiums, comprises between 16% and 34% of household budgets in the United States. As healthcare costs continue to rise, our findings suggest that households that obtain their health insurance on the individual (i.e., not employer sponsored) market in states with MCLs appreciate significantly lower premiums.

Coverage Gaps and Inconsistencies: The Landscape of Insurance Coverage for Orthognathic Surgery in the United States

Background: Despite established indications for orthognathic surgery, insurance coverage is not guaranteed and obtaining coverage is often onerous. There is a paucity of literature regarding insurance coverage within the United States for orthognathic surgery. Methods: The top 50 health insurers in the US, and the top 3 per state, were selected using the National Association of Insurance Commissioners (NAIC) 2020 Market Share Report. Coverage policies were obtained online, or by phone when unavailable. Indications and criteria were compared to the American Association of Oral and Maxillofacial Surgeons (AAOMF) “Criteria for Orthognathic Surgery” recommendations. Results: Of the 65 insurance providers reviewed, 33 offered coverage with clear criteria, 24 offered coverage without listed criteria, and 8 explicitly excluded all orthognathic surgery. The 33 insurers with clear criteria were further reviewed. For malocclusion, 20 insurers used at least 75% of AAOMF measurements, while 4 used stricter criteria. Eleven insurers covered surgery for any congenital disorder; of the remaining, only 13 explicitly covered cleft-associated abnormalities. For the 25 with specified speech anomaly criteria, 21 offered coverage, and 4 excluded coverage. Sleep apnea coverage criteria were inconsistent, and temporomandibular joint disorder (TJMD) coverage was evenly split. No insurer covered orthognathic surgery for esthetic or psychological reasons. Among 66 identified unique criteria, only 6 significantly differed by US Census Region, with coverage for sleep apnea more prevalent in the South District. Conclusions: Access to insurer policies remains difficult. Insurers have inconsistent covered indications, strictness of coverage criteria, and exclusions, which frequently do not match standards of care. The authors present a list of the most commonly used criteria as a resource for insurance submissions, and encourage surgeons to advocate at the insurer and legislative levels for consistent coverage indications and criteria across insurance providers.

(218) Emerging Data Regarding Disparities in Insurance Coverage of Male Sexual Health Conditions

Abstract Introduction Medical policy bulletins (also known as clinical policy bulletins) are insurance company guidelines for administering plan benefits. These documents purport to summarize current research, evidence-based guidelines, regulatory status, and physician opinion to determine whether insurers consider procedures and services to be medically necessary. These bulletins, along with member benefit plans, determine which services are covered. We have previously explored the lack of uniformity that exists for insurance payer coverage for penile prostheses. Here, we sought to expand this investigation to determine insurance coverage criteria for medical and surgical management of common men’s health conditions. Objective To determine covered benefits for sexual medicine conditions among the top United States healthcare insurers. Methods A list of common sexual medicine conditions was generated, including Peyronie’s disease, hypogonadism, erectile dysfunction, premature ejaculation, incontinence, and buried penis. The most common treatment modalities for each condition were identified (see Table I). Securities and Exchange Commission (SEC) filings were used to identify the top ten largest private insurers in the United States by member enrollment. This list was cross-referenced with the National Association of Insurance Commissioners (NAIC) 2020 Market Share Report (ref 1). The following list of the largest private US health insurers was thus developed: United, Anthem, Centene, Kaiser, Humana, CVS, Healthcare Service Corporation (HCSC), Cigna, Molina, and Independence Health Group (IBX). Kaiser and Centene were excluded due to lack of nationwide medical policy bulletins. We reviewed medical policy bulletins from the remaining 8 insurers to determine whether the specific treatments were identified as medically necessary, experimental/investigational, or cosmetic. Services and procedures deemed medically necessary were coded as “covered,” and those listed as investigational, or cosmetic were coded as “not covered.” If information about a specific condition or treatment modality was not found in a company’s policy bulletin, it was coded as “unknown.” Results In total, we recorded 143 data points, across the 8 insurance providers. Our review of medical policy bulletins yielded 60 (41.9%) instances where services were considered medically necessary and/or “covered”, 18 (12.6%) non-covered or investigational/cosmetic services, and 65 (45.5%) services with unknown coverage (Table I; covered=1, non-covered=0, unknown=2). Conclusions We encountered substantial difficulty in navigating and interpreting insurance coverage for various sexual medicine treatments and conditions based on review of policy bulletins from the topic insurance providers in the US. There was no readily identifiable coverage information for >45% of the data points that we collected, and instances of “unknown” coverage exceeded covered services across the collective of the largest private insurers. While 76.9% of conditions for which there was available data were covered, we are unable to draw generalizable conclusions for most conditions as there are significant deficits in the availability of policy information from online insurance sources. Further challenges in determining coverage include the additional layers of limitations in member plan benefits (i.e. plan exclusions), which could compound confusion for both physicians and patients. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast.

The US Supreme Court and Future of Financing Dialysis Care.

The US Supreme Court and Future of Financing Dialysis Care.

Congress Extends Enhanced ACA Subsidies.

Congress extended enhanced Marketplace subsidies through 2025 and adopted historic Medicare prescription drug reforms.

Doubly Enhanced Medicaid Partnership Annuities (DEMPANs): A New Tool for Providing Long Term Care to Retired U.S. Seniors in the Medicaid Penumbra

A major problem facing many U.S. retirees is accessing and paying for long term care. The 2019 National Association of Insurance Commissioners (NAIC) guide on long-term care insurance estimates that, of the individuals living in the United States who reach age 65, about 70% are expected to need some form of long-term care at least once in their lifetime and about 35% are expected to enter a nursing home at least once in their lifetime. Although Medicare covers most of a U.S. retiree’s medical care, Medicare does not ordinarily pay for long-term care. U.S. retirees often can access long-term care services via the Medicaid program, which is a means-tested program geared to lower income Americans. But, to quickly qualify for Medicaid, many retirees take drastic steps, such as transferring their assets to family members. When access to long-term care is not urgent and long-term planning is an option, most U.S. states have developed so-called Partnership for Long-Term Care (PLTC) Program insurance policies that provide access to Medicaid services while sheltering some or all of a retiree’s assets. In this article, we propose a hybrid annuity product called a doubly enhanced Medicaid partnership annuity (DEMPAN) that combines an annuity with a long-term care rider that is integrated within the framework of a qualified partnership policy. (Outside the United States, bundled retirement products similar to DEMPANs are often called life-care annuities.) To analyze our DEMPANs, we use a multistate model of long-term care with health states that are based on a retiree’s ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs) and cognitive ability. A significant contribution of this article is to explicitly model how the quality of long-term care a retiree receives affects the retiree’s health state transition probabilities used in the multistate model. As higher quality of care usually comes at a higher cost but with better health outcomes, we provide an example that explores an expected discounted utility maximizing retiree’s optimal choice of DEMPAN. Our example showed that it may be optimal for retirees who purchase DEMPANs to simply buy average quality long-term care. We hope DEMPANs fill a gap in the long-term care market by providing an important tool for elder care planning for those in the Medicaid penumbra (i.e., in the middle- and lower-middle-income classes). Retirees who purchase DEMPANs have the benefits of an annuity, private long-term care, Medicaid assistance with paying their long-term care bills, and some degree of asset protection from Medicaid estate recovery.

Copula based Bayesian data analysis of loss reserving

Prediction of loss reserves corresponding to dependent lines of business is one of the most important problems in the actuarial sciences. In this paper, we propose a class of copula based multivariate distributions to model the losses with the heavy tailed distribution in the run-off triangles to predict unpaid losses. We set up ANOVA, ANCOVA, and state space models with four choices of copulas, Clayton, Frank, Gumbel, and Gaussian to provide a new procedure for analyzing run-off triangle tables. We use the Hamiltonian Monte Carlo sampler to perform a Bayesian analysis to estimate the parameters. We apply the proposed models to the data set consists of two lines of business of paid losses data from the Schedule P of the National Association of Insurance Commissioners (NAIC) database. Using some well known criteria, we compare the prediction accuracy of the mean models. As a result, the ANCOVA model with the Clayton copula dominates the other models.

APA’s Government, Policy, and Advocacy Update

Back to table of contents Previous article Next article Government & LegalFull AccessAPA’s Government, Policy, and Advocacy UpdateSearch for more papers by this authorPublished Online:30 Mar 2021https://doi.org/10.1176/appi.pn.2021.4.34APA Leaders Applaud Passage of the American Rescue Plan Act of 2021APA’s leaders praised the inclusion of several provisions related to mental health in the American Rescue Plan Act of 2021 (HR 1319). The legislation includes about $4 billion in funding for programs that support the prevention of and treatment for mental and substance use disorders.“We will not recover sufficiently from this pandemic long term unless we address our mental health with the same urgency and attention as our physical health,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A., in a news release. “This package is a huge step in the right direction, and we look forward to working with Congress and the administration to implement policies and services that will help all our patients.”APA supported several provisions in the legislation, including funding for mental and substance use disorder services through programs including the Community Mental Health Services and Substance Abuse Prevention and Treatment block grants, Certified Community Behavioral Health Clinics, and the National Child Traumatic Stress Network, as well as expanded eligibility for premium assistance under the Affordable Care Act, increased Medicaid funding, and funding to promote mental health integration with pediatric primary care.“It is essential and heartening that Congress and the administration included funding for our nation’s mental health system in this wave of COVID relief,” APA President Jeffrey Geller, M.D., M.P.H., said in the news release.APA Urges Governors to Make Telehealth Flexibilities PermanentAPA and eight other medical organizations, representing more than 350,000 physicians, sent a letter to state governors urging them to support legislation and regulations to permanently retain the telemedicine rules that had been relaxed at the start of the COVID-19 pandemic. The letter was sent to the National Governors Association, the National Conference of State Legislators, and the National Association of Insurance Commissioners.“The ability to see a patient via telemedicine should be driven by clinical decision making over any other factors,” the letter stated. “When the public health emergency ends, telemedicine should remain an option for providing care.”ATTAIN Act Receives APA EndorsementLast month, Sens. Deb Fischer (R-Neb.) and Tina Smith (D-Minn.) reintroduced the Achieving Through Transparency and Accountability for Information Navigation (ATTAIN) on Mental Health Act. The legislation aims to create an online dashboard through which applicants, such as nonprofits, mental health treatment facilities, or state and local educational agencies, can identify federal grants that support mental health initiatives.APA supports the bill. In a news release, APA President Jeffrey Geller, M.D., M.P.H., said the bill is a “good first step” to ensure access to mental health funding for communities in need.“As the COVID-19 pandemic has continued, we have seen an increase in rates of anxiety, depression, suicide, and other mental illnesses,” Geller continued. “Providing states, localities, and other organizations with easy-to-access information regarding available federal funding for mental health programs will help them meet the increasing need for treatment faster.”APA, Partner Organizations Offer Recommendations to BidenIn a letter to President Joe Biden, APA and five of its partner organizations—collectively known as the Group of Six—outlined several health care issues that they urged the president to prioritize.The recommendations include implementing a science-based and public health approach to end the COVID-19 pandemic, expanding health care coverage and protecting access to care, expanding and strengthening Medicaid, improving health care for women, and ending interference in the patient-physician relationship, addressing physician workforce issues, addressing health disparities, and reducing the administrative burden in health care. ■ ISSUES NewArchived

The COVID-19 Pandemic and Health Insurance Regulation

With projections of costs in the billions for COVID-19 treatments alone, and heightened scrutiny on COVID-19-related health insurance coverage, the National Association of Insurance Commissioners (NAIC) convened in March 2020 to discuss how the industry could best deal with a pandemic. While the ramifications of the COVID-19 event are in their infant stages, it is important to consider the implications such catastrophic risks have on an insurance market. We evaluate state-level changes presented by the NAIC in response to the COVID-19 pandemic and use prior research to offer insight into health insurance in a post-COVID-19 world. This manuscript aims to provide a summary of the NAIC’s current standing during the pandemic, while presenting insight into policy implications regarding regulation in health insurance markets during catastrophic events.

The Election; The ACA At The Supreme Court.

The new president will put his stamp on the Affordable Care Act as the Supreme Court seems unlikely to invalidate the entire law.

Contraceptive Mandate, ACA Final Rules, And COVID-19.

The Supreme Court upheld broad exemptions to the Affordable Care Act contraceptive mandate; new ACA rules were finalized.

The New EU Rules on Insurance Customer/Policyholder Protection Viewed against the NAIC Model Acts

Abstract Effective October 1, 2018, the Member States of the European Union had to bring into force the laws, regulations and administrative provisions necessary to comply with Directive (EU) 2016/97 of the European Parliament and of the Council of January 20, 2016 on insurance distribution (IDD). The IDD arose out of a desire to give insurance customers equal protection regardless of the type of distributor from which they obtained insurance. Essentially, the IDD seeks to level the playing field of protections for insurance customers by simplifying, consolidating, and expanding customer protections when needed. The IDD has the stated goal of focusing on “the area of the disclosure of information” to customers. The directive is intentionally broad and applies “to persons whose activity consists of providing insurance or reinsurance distribution services to third parties.” Although it is much too early to predict the course of the IDD within the European Union, a comparison can be drawn with the Model Acts promulgated by the National Association of Insurance Commissioners (NAIC) in the United States to glean an inkling as to where the IDD might be headed. Parts of the Model Acts have been in place for a number of years and, while the legal regimes they cover are modestly different, there are nonetheless broad lessons that can be drawn in the comparison of the two. Whether the path of the IDD follows the arc of the Model Acts, or not, will perhaps be attributed to three instrumental aspects: 1. The IDD is unquestionably focused on customer protection. The NAIC is more nearly concerned with uniformity. It may be that the IDD’s focus will contribute to better traction among the EU Member States then Model Acts have experienced in the United States. 2. Unlike the IDD, the NAIC Model Acts are not comprehensive with respect to customer protection. 3. The NAIC Model Acts have seen inconsistent adoption by the states, a factor that has contributed to a lack of uniformity and constancy across any number of insurance products. While the IDD should not suffer from spotty adoption, the relative flexibility of the EU Member States in adopting more stringent rules may lead to a lack of uniformity and consistency similar to that of the Model Acts. Thus, the IDD may very well face the same headwinds faced by the Model Acts in the United States. Accurate predictions are always elusive when dealing with the implementation of regulation and legislation. Accordingly, we will watch with curiosity whether the IDD, which takes a much more global approach in customer protection, will see more success.

Texas Ruling Brings More ACA Uncertainty.

Texas ruling and other legal challenges raise questions about the ACA's future even as enrollment holds steady.

Claim reserve prediction using the credibility theory for the Chain Ladder method

A claim reserve is a reserve that must be prepared by a long-tail business insurance company to fulfil its obligations to future policyholders. One of the most popular methods for predicting claim reserves is the Chain Ladder method. However, on the Chain Ladder method, the claim reserve is predicted solely based on individual information (information derived from the company’s past experienced). If the individual information is not enough, an actuary needs to consider other information that is collective information (market experience). Both information can be combined by applying Bühlmann-Straub credibility theory. This paper will discuss about implementation of credibility theory for the Chain Ladder method to predict claim reserve for the data of private passenger autoliability/medical insurance in 1998-2007 are published by National Association of Insurance Commissioners (NAIC).

Financial advisor titles: Informational complexity and the role of regulatory simplification

AbstractToday's complex financial markets require high levels of financial literacy that most consumers do not possess. Consumers may choose to mitigate their information disadvantage by hiring a financial professional. In searching for such a professional, however, consumers will find a multitude of financial advising titles that may or may not signal competence, education, and professionalism. Various regulatory bodies, and piecemeal regulation over the past 80 years, have resulted in an incoherent code of law. Two narrow protections for senior citizens specifically address financial credentials, however. These model regulations were drafted by the National Association of Insurance Commissioners (NAIC) and the North American Securities Administrators Association (NASAA) in 2008. This commentary explores why some states have adopted these regulations while others have not and notes the need for research to systematically evaluate the effectiveness of such regulations.

Texas Arguments Lead Heavy ACA Action.

Arguments in Texas raise questions about the ACA's fate as enrollment holds steady and new state reinsurance waivers are approved.

Serious misdiagnosis-related harms in malpractice claims: The "Big Three" - vascular events, infections, and cancers.

Background Diagnostic errors cause substantial preventable harm, but national estimates vary widely from 40,000 to 4 million annually. This cross-sectional analysis of a large medical malpractice claims database was the first phase of a three-phase project to estimate the US burden of serious misdiagnosis-related harms. Methods We sought to identify diseases accounting for the majority of serious misdiagnosis-related harms (morbidity/mortality). Diagnostic error cases were identified from Controlled Risk Insurance Company (CRICO)'s Comparative Benchmarking System (CBS) database (2006-2015), representing 28.7% of all US malpractice claims. Diseases were grouped according to the Agency for Healthcare Research and Quality (AHRQ) Clinical Classifications Software (CCS) that aggregates the International Classification of Diseases diagnostic codes into clinically sensible groupings. We analyzed vascular events, infections, and cancers (the "Big Three"), including frequency, severity, and settings. High-severity (serious) harms were defined by scores of 6-9 (serious, permanent disability, or death) on the National Association of Insurance Commissioners (NAIC) Severity of Injury Scale. Results From 55,377 closed claims, we analyzed 11,592 diagnostic error cases [median age 49, interquartile range (IQR) 36-60; 51.7% female]. These included 7379 with high-severity harms (53.0% death). The Big Three diseases accounted for 74.1% of high-severity cases (vascular events 22.8%, infections 13.5%, and cancers 37.8%). In aggregate, the top five from each category (n = 15 diseases) accounted for 47.1% of high-severity cases. The most frequent disease in each category, respectively, was stroke, sepsis, and lung cancer. Causes were disproportionately clinical judgment factors (85.7%) across categories (range 82.0-88.8%). Conclusions The Big Three diseases account for about three-fourths of serious misdiagnosis-related harms. Initial efforts to improve diagnosis should focus on vascular events, infections, and cancers.