Sensing a fresh threat to state and federal healthcare reforms, California insurance officials are seeking new limits on a controversial form of health coverage insurers are selling to small employers.
At issue is a new type of self-insurance for small businesses with as few as 25 workers.
Critics said insurers such as Cigna Corp. are using these new plans to game the system and cherry-pick companies with healthier workers. They said this could undermine a key goal of the federal Affordable Care Act to lower premiums by pooling together more healthy and sick Americans into insurance exchanges.
Premiums could continue to escalate without a diverse pool of consumers. That prospect has federal health officials weighing action against this practice as well.
Insurance officials say that they are responding to employer demands for more affordable coverage and that regulators shouldn't interfere in the market. Mike Ferguson, chief operating officer at the Self-Insurance Industry Institute of America, a trade group, said there's no evidence that insurers are targeting companies with healthier employees.
For The Record
Los Angeles Times Saturday, March 24, 2012 Home Edition Main News Part A Page 4 News Desk 1 inches; 38 words Type of Material: Correction
Health plans: A March 23 article in the Business section about state regulators' concern over a form of health coverage for small businesses misidentified the trade group Self-Insurance Institute of America as the Self-Insurance Industry Institute of America.
For The Record
Los Angeles Times Sunday, April 01, 2012 Home Edition Main News Part A Page 4 News Desk 2 inches; 71 words Type of Material: Correction
Health plans: An article in the March 23 Business section about California insurance officials proposing limits on a form of health coverage insurers are selling to small employers quoted Wake Forest University professor Mark Hall as saying low-dollar stop-loss policies, which guarantee that businesses won't be responsible for medical expenses over a certain amount per employee, are a "sham." In fact, Hall was referring specifically to plans with zero-dollar stop-loss policies.
"We are concerned about regulators' actions because self-insurance is arguably one segment of the healthcare market that is working well," Ferguson said. "These companies are generally able to control costs better and offer more customized benefits."
Self-insurance, in which employers pay medical providers for their workers' care, has traditionally been used only by large employers that have the financial resources to pay for expensive medical claims. A Kaiser Family Foundation study found that 60% of U.S. workers with health coverage were in self-insured plans last year.
Now some insurers are chasing after much smaller customers with new plans designed to limit employer payouts for big claims using what's called stop-loss policies. This guarantees that businesses won't be responsible for anything over a certain amount per employee, perhaps as low as $10,000 or $20,000, with the rest paid by an insurer. Regulators and health-policy experts say this arrangement undercuts the notion of self-insurance since employers aren't bearing much of the risk, and it allows companies to circumvent some state insurance rules.
"This is not real self-insurance. This is clearly a sham," said Mark Hall, a professor of law and public health at Wake Forest University who has studied the small-business insurance market. "Regulators have good reason to be concerned about the potential harm to the market."
Self-insurance is attractive for many reasons, particularly the prospect of lower costs. It's exempt from state insurance regulations such as mandated benefits, granting employers the flexibility to design their own benefit package and the opportunity to reap some of the savings from employee wellness programs. A federal law, the Employee Retirement Income Security Act, or ERISA, governs self-funded plans. Some aspects of the Affordable Care Act do apply to self-insurance, such as the elimination of caps on lifetime benefits and some preventive care at no cost.
California Insurance Commissioner Dave Jones will unveil proposed legislation next week that would bar insurers from selling stop-loss policies below a certain amount. The specific dollar figure is still under consideration, but some experts recommend a minimum of $40,000 per worker. This proposal would make these new self-insured plans less attractive for small employers because they would be on the hook for more employee medical bills.
"The goal of the legislation is to help ensure the success of the small group market as significant healthcare reforms are going into effect," said Janice Rocco, California's deputy insurance commissioner for health policy. "There's a concern carriers are selling a product that's not really appropriate for small groups."
Officials in the Obama administration are keeping a close eye on developments in California and other states where insurers are aggressively selling these plans.
"We are working carefully to ensure that consumers in all markets have the protections guaranteed by the Affordable Care Act and will provide more clarity on the tools available to reinforce these protections soon," a spokesman for the U.S. Department of Health and Human Services said.
Monday, the U.S. Supreme Court will begin hearing arguments over the constitutionality of the federal healthcare law and its mandate that individuals purchase health insurance.
About 3 million Californians get health coverage through small businesses with fewer than 50 employees while 15 million are insured through larger employers, according to the California HealthCare Foundation. Small businesses are eager for new options since the average premium for employer coverage in California has increased 154% over the last decade, more than five times the 29% increase in the state's overall inflation rate.