The state’s request to ease new federal restrictions on health insurer spending would cost Georgia insurance policyholders an estimated $34 million in rebates, consumer advocacy groups say.
The consumer groups sent a letter Friday urging U.S. Health and Human Services Secretary Kathleen Sebelius to reject Georgia Insurance Commissioner Ralph Hudgens’ request for a waiver on rules governing how insurers can spend money.
The restrictions come under a broad category called “medical loss ratio.’’ The 2010 health reform law, also known as the Affordable Care Act, requires companies to spend at least 80 percent of the premium dollars on medical care costs under policies bought by individuals.
Insurers that miss the 80 percent mark have to pay rebates to individual policyholders, beginning in January. A state can get an adjustment if it shows the requirement would disrupt the market for policies sold to individuals.
An estimated 350,000 Georgians have individual health policies. That market currently “is a minefield,’’ said Cindy Zeldin of Georgians for a Healthy Future, which, along with Georgia Watch, is a lead group fighting the exemption request. She cited the high price of coverage and the lack of transparency on benefits among problems with individual policies in Georgia.
The 80 percent rule gives insurers an incentive “to operate more transparently and provide better value,’’ Zeldin said Monday. If Georgia’s waiver request is approved, and that incentive is altered, consumers would get rebates of about $8 million instead of $42 million, the consumer groups say.
The Georgia Association of Health Plans, which represents major insurers, noted that Hudgens’ request is not to eliminate the 80 percent medical loss ratio (MLR), but to allow insurance companies to meet it gradually, with a 65 percent mark in 2011, 70 percent in 2012 and 75 percent in 2013.
“Certainly we’d like a stepped approach,’’ said Graham Thompson, executive director of the Georgia Association of Health Plans.
Insurers also support allowing other costs into the 80 percent calculation, such as agent compensation and fraud prevention efforts, Thompson said. Currently those costs are included in the 20 percent of revenues that insurance companies can use for administrative expenses and profit, he said.
Several states have requested federal waivers to ease the percentages that insurers must comply with as part of the Affordable Care Act. Maine, Kentucky and Iowa are among states that received waivers, while Delaware and North Dakota were denied their requests.
Advocacy groups fighting the Georgia waiver include the American Heart Association, AARP Georgia, the Georgia Breast Cancer Coalition Fund, Voices for Georgia’s Children, the American Cancer Society, and the League of Women Voters of Georgia.
The MLR rules accompany new reviews of insurers’ proposed rate increases at or above 10 percent for individual and small-group policies, as part of a group of insurance reforms in the Affordable Care Act.
Jim Beck, chief of staff for the state insurance department, said Hudgens disagrees with the groups’ argument that waiving the new requirement would hurt consumers.
“Enforcing the new requirement so quickly could hurt Georgians by driving some insurers out of the individual market,’’ Beck said Tuesday in a statement. The agency “is not asking that the MLR standard be thrown away; we are simply asking for it to be implemented in a graduated manner.
“The commissioner’s office already takes calls daily from consumers having difficulty getting coverage, and no one wants to see more consumers put in that predicament because of the possibility of insurers being forced out of the marketplace.’’
Thompson said insurers’ current MLR in Georgia averages “somewhere in the mid-60s,’’ though it varies widely by company. Applying the current 80 percent rule immediately would cause some market disruption, he said.
But Zeldin said that none of Georgia’s more than 20 health insurers offering individual policies has given notice of an intent to leave the state. The requirements on smaller insurers are much less stringent than on companies with more than 75,000 policyholders, she added.
HHS recently determined that Georgia’s request for a waiver contains sufficient data for a decision. The federal agency is expected to make that determination within 60 days.
Thompson said health insurers “are hopeful for a favorable outcome. We’re glad to be working with Commissioner Hudgens and HHS.’’
Federal approval of Georgia’s waiver would transfer $34 million over three years from consumer rebates to insurers’ profits, the advocacy groups say.