畢業(yè)設(shè)計(jì)外文參考資料及譯文-醫(yī)療保險(xiǎn)改革(編輯修改稿)
2025-01-07 08:09 本頁面
【文章內(nèi)容簡(jiǎn)介】 Rules. There are four main types of rate regulation in place in the individual and small group markets today: Actuarial Justification: In markets with actuarially justified rating requirements, insurers must demonstrate a correlation between characteristics of the insured and increased medical claims costs. The NAIC has adopted safe harbors for case characteristics monly used for setting premiums within which plans may generally vary rates without providing justification. Plans that vary rates in excess of these safe harbors may be required to submit data for justification. This is the most mon form of rate regulation in the individual and large group markets Rating Bands: Particularly in the small group market, many states have implemented rating bands that limit the variation in premiums attributable to health status and other characteristics. Rating bands are either expressed as a ratio of the highest rating factor to the lowest (., :1) or as the allowable variation above and below an index rate (., +/ 30 percent). Composite rating bands may be used to limit the bined effects of multiple case characteristics (., a posite rating band that allows 4:1 variation based upon health status, age, gender, industry, and group size bined). Ting BandsHybridMichigan Blue Cross/Blue Shield must use munity rating. There is no rating structure for other carriers. Individual Market Rating RulesDCAdjusted Community Rating Community RatingNo Rating Structure regulation is rarely used. Adjusted Community Rating: Adjusted (or modified) munity rating laws prohibithe use of health status or claims experience in setting premiums. Other case characteristics, such a age and geography, may be used to vary premiums, though limits may be placed upon these factors Community Rating: Pure munity rating laws prohibit the use of any case charactebesides geography to vary premiums. This form of rate Key Patient Protections Mandated Benefits. States have adopted a variety of benefit mandatessome more than others. These mandates require carriers to include in their policies coverage of certain services, ., chiropractic care, prenatal care, mental health services, etc. Access to Providers. States have adopted laws requiring insurers to reimburse certain classes of providers for services that are covered by the plan (., psychologists who provide mental health care covered under the policy). States have also enacted laws ensuring access to emergency services, specialists, pediatricians as primary care providers for children, and others. Grievance and Appeals Rights. State laws ensure enrollees have timely access to internal and external appeals processes to resolve questions regarding coverage or edical necessity?decisions and to grievance procedures. Oversight of Marketing Practices. States require that marketing materials be easily readable and not misleading or fraudulent. Insurance regulators have authority to review marketing information to ensure they ply with Unfair Trade Practices laws and other regulations. States also license and oversee the activities of insurance agents and brokers to protect consumers from false or misleading materials or claims. Review of Market Conduct. State regulators use market conduct exams, corrective action plans, and penalties to make sure carriers ply with state laws and regulations and conduct themselves in a way that is not detrimental to consumers. Prevention of Fraud. States identify fraudulent plans and work with other states and the federal government to shut them down and prosecute the anizers. Public education campaigns have been effective
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