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Author: Craig "Moondog" Palosky

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  • Health Insurance Market Reforms: Pre-Existing Condition Exclusions

    Fact Sheet

    Insurers pursue multiple strategies to reduce the cost of covering enrollees with pre-existing conditions, or medical conditions and health problems that existed before the individual enrolled in a health plan. One strategy, the pre-existing condition exclusion, allows insurers to refuse to cover any costs associated with care for a pre-existing condition permanently or over a period of time. Beginning January 1, 2014, insurers in the individual and group markets will be prohibited from imposing pre-existing…

  • Quantifying the Effects of Health Insurance Rate Review

    Report

    This report from the Kaiser Family Foundation analyzes the effect of government efforts to ensure that insurance premium increases are justifiable and provide value to consumers and small businesses. Rate review programs require insurers in the small group and individual markets to submit proposed rate increase requests to state or federal regulators, who determine if the requests are reasonable. The report finds that one out of every five requests submitted to states in 2011 resulted…

  • National and State-By-State Impact of the 2012 House Republican Budget Plan for Medicaid

    Report

    This analysis of the House Budget Plan that was passed in 2012 finds that repealing the Affordable Care Act (ACA) and converting Medicaid to a block grant would trigger significant decreases in federal Medicaid spending and could result in substantial reductions in enrollment and payments to providers compared to current projections. The analysis, conducted by the Urban Institute for the Kaiser Family Foundation’s Commission on Medicaid and the Uninsured, updates a similar study from May…

  • Transparency and Complexity

    Perspective

    This fall a new rule takes effect requiring all private health plans to offer a uniform, simple to read, summary of benefits and coverage (SBC).  The SBC will provide consumers with standardized information about how plans cover essential health benefits and what coverage limits and cost sharing applies. The SBC is one of the most popular provisions of the ACA.  Consumers often find health insurance difficult to understand and would no doubt welcome a plainly written…

  • Program Integrity in Medicaid: A Primer

    Issue Brief

    Medicaid covers more than 60 million Americans and accounts for about one in six dollars spent on health care in the United States. Multiple agencies at the state and federal levels are involved in efforts to prevent waste, fraud and abuse in the program and ensure appropriate use of taxpayer dollars, and many program integrity initiatives are yielding positive results. The Affordable Care Act (ACA) builds on earlier efforts through the Deficit Reduction Act to…

  • Health Insurance Market Reforms: Rate Restrictions

    Fact Sheet

    Rate restrictions limit how much insurance companies can vary premiums charged to individuals and businesses based on factors such as health status, age, tobacco use and gender. Currently, federal law does not place any limits on the ways that insurance companies set their premium rates. However, beginning January 1, 2014, insurance companies must meet the Affordable Care Act's minimum premium rating rules for health plans for individuals and small businesses. This brief explains the current…

  • Health Insurance Market Reforms: Guaranteed Issue

    Fact Sheet

    Guaranteed issue laws require insurance companies to issue a health plan to any applicant - an individual or a group - regardless of the applicant's health status or other factors. Currently, in most states, insurance companies can deny nongroup coverage to people based on their health status or their medical expenses over the past year. This means that an uninsured person who develops a certain condition, such as breast cancer, might not be able to…

  • Insurer Rebates under the Medical Loss Ratio: 2012 Estimates

    Report

    Beginning in 2011, the Affordable Care Act (ACA) requires insurance plans to pay out a minimum percentage of premium dollars towards health care expenses and quality improvement activities, limiting the amount spent on administrative and marketing costs and profit. Under the law, large group plans are required to spend at least 85 percent of premium dollars on health care and quality improvement, while small group plans must spend at least 80 percent. These ratios are…

  • A Guide to the Medicaid Appeals Process

    Issue Brief

    This background brief provides a comprehensive look at the appeals process for the Medicaid program, which differs significantly from those available through the Medicare program and private health insurance. The Medicaid appeals process provides redress for individual applicants and beneficiaries seeking eligibility for the program or coverage of prescribed services, but the process is multi-layered and can be complex to navigate. The guide describes Medicaid's appeals system, including the fair hearing process and the appeals…