毕业设计(论文)外文参考资料及译文-医疗保险改革.doc

毕 业 设 计（论 文）外 文 参 考 资 料 及 译 文 译文题目： 医疗保险改革 学生姓名： 赵 峥 唐 学 号： 0721110325 专 业： 金 融 学 所在学院： 龙 蟠 学 院 指导教师： 王 泓 颖 职 称： 副 教 授 2011 年 3月 9 日 Health Insurance Reforms Written by: Josh Goldberg and Brian Webb, National Association of Insurance CommissionersThe health insurance markets in many states have struggled to maintain affordable plan options for small businesses and individuals. Access to coverage in the individual markets of most states continues to be severely limited for people with preexisting conditions. In addition, the large year-over-year increases in health care spending drive premiums ever higher. The small group market remains unavoidable and unpredictable for many small business owners who struggle to continue to offer coverage as premiums increase. Without more regulation or incentives to facilitate greater enrollment across a wide range of individuals in the market, these problem will persist.A number of congressional proposals would directly influence health insurance oversight and market conditions. However, in the absence of federal action, it will again fall to the states to craft their own solutions to these vexing problems, which will be complicated by the political polarization spawned by the federal health reform debate and the severe budget difficulties most states are currently facing.States have been and will continue to be, with or without federal reform, at the forefront of innovation in health care, making them, in the words of Justice Louis Brandeis, he laboratories of democracy.Over the years, many states have forged ahead in enacting and implementing a wide variety of reform strategies. Indeed, much of the federal legislation enacted to improve health coverage in this country, like the Health Insurance Portability and Accountability Act of 1997, has been based upon successful state reforms.Overview of Current RegulationHealth insurance regulation is essentially a mix of federal and state oversight. In general, the states regulate health insurance. However, the federal government has, over time, adopted laws and regulations that have overlaid federal autonomy. Today, approximately 36 percent of health coverage falls under the jurisdiction of state regulators.The Employee Retirement Income Security Act (ERISA) of 1974 established the federal government as the regulator of employer-provided benefits, including health insurance. Under ERISA, the federal government regulates the employer-employee relationship, but the authority of states to regulate private insurance purchased by the employer is preserved. If the employer does not purchase insurance, instead choosing to self-insure (bear the risk themselves), then state laws are preempted. Government plans are also exempt from state oversight.The Health Insurance Portability and Accountability Act (HIPAA) of 1996 established minimum federal standards for the regulation of, primarily, small group coverage. If a state law does not meet the minimum standards, then that state law is preempted and the federal government regulates.Beyond these federal preemptions, states oversee and regulate the individual and small group markets, and other aspects of private health insurance. The following section briefly describes the state regulatory framework, including market regulation, business and operations oversight, and consumer protections. Health Insurance MarketsIndividual Market. The individual (or non-group market is solely regulated by the states. In most states, this market is populated by those who are self-employed or do not have access to coverage through their employer.Small Group Market. The small group market, in most states, consists of employers with between 2 and 50 employees. Some states include groups of 1 (the self-employed) and can also include employers with up to 100 employees.Large Group Market. The large group market is composed of employers with too many employees to purchase in the small group market and are not self-insured, thus falling under state regulation.Licensee and Solvency All states require health insurance carriers to be licensed before they can sell health insurance in the state. During the licensure process, the state reviews the background of the owners and board as well as the business plan, finances, and other information to determine whether they meet minimum state requirements.States establish minimum solvency standards for health insurance carriers to ensure they have sufficient funds to meet their obligations. The National Association of Insurance Commissioners (NAIC) assists states in reviewing quarterly and annual financial statements to identify any potential problems in a timely manner. Access to CoverageGuaranteed Issue. HIPAA established a national standard that all small group plans must be guaranteed issue-o small employer may be denied coverage. An individual who had creditable group coverage is guaranteed access to an individual plan designated for IPAA-eligible by the state. All states have laws that meet this minimum standard, while a few states have extended guaranteed issue to the individual market.Preexisting Condition Exclusion Limitation. HIPAA established a national standard for group coverage that limits preexisting condition exclusions-provisions in a policy that exclude coverage of care related to a particular disease, disability, ailment, etc. that was identified by the patient or their doctor during the look back period prior to the consumer purchasing the coverage. The HIPAA standard allows for a 6-month look back period and limits the exclusion period to 12 months. The exclusion period is reduced by a month for every month the person had creditable coverage without a significant gap prior to enrollment. States may create a more stringent, but not less stringent, approach to preexisting condition exclusions.High-Risk Pools. Thirty-five states have created high-risk pools to provide health care coverage for uninsurable individuals and families. Typically, a consumer must have been denied coverage in the individual market before they can enroll in the high-risk pool and premiums are capped at 150-200 percent of the average rate in the individual market. The pools are primarily funded by assessments on health insurance carriers.Dependent Coverage. Many state laws require insurance carriers to allow enrollees to purchase coverage for dependents over age 18, up to a certain age. This requirement is often limited to unmarried children or children in school.Forms and RatesReview of Policy Forms and Rates. Insurance carriers are required to submit policy forms (contracts) and premium rates to the Department of Insurance. Some states require prior approval before the forms and/or rates can be used; others require the forms and/or rates to be filed for review or informational purposes only. Carriers must certify that the policy forms meet the requirements of state law and that the premium rates comply with state rating rules.Rating 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 commonly 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 common form of rate regulation in the individual and large group marketsRating 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 (e.g., 1.5:1) or as the allowable variation above and below an index rate (e.g., +/- 30 percent). Composite rating bands may be used to limit the combined effects of multiple case characteristics (e.g., a composite rating band that allows 4:1 variation based upon health status, age, gender, industry, and group size combined). Ting BandsHybridMichigan Blue Cross/Blue Shield must use community 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) community 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 factorsCommunity Rating: Pure community rating laws prohibit the use of any case charactebesides geography to vary premiums. This form of rate Key Patient ProtectionsMandated Benefits. States have adopted a variety of benefit mandates-some more than others. These mandates require carriers to include in their policies coverage of certain services, e.g., 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 (e.g., 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 comply 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 comply 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 organizers. Public education campaigns have been effective in making consumers aware of such plans. Federal Insurance ReformsThe Congress has offered a number of reforms that directly influence current state efforts in insurance regulation and oversight. These reforms may imminently become law, creating the need for immediate state action and longer term implementation efforts. The following is a review of the major components of that reform package, including any known flexibilities and deadlines.Immediate ReformsTemporary High Risk Pool Program. The legislation would provide $5 billion for the immediate creation of a federal program to subsidize coverage through high risk pools to uninsured individuals with preexisting conditions. There may also be other ways that states could access these funds to provide coverage.Medical Loss Ratios. Insurers would have been required to spend a specified percentage of premiums on health care or other services that improve health care quality and provide rebates to consumers for excess nonmedical expenditures.Rate Review. Perhaps in separate legislation, the Congress is considering authorizing the Secretary of HHS to work with states in eliminating unreasonable rate increases in insurance products. Through a rate review process in states or at the federal level, the legislation would allow for the denial or remediation of unreasonable increases in insurance rates or premiums. Preemption may be considered.Reforms to be Implemented by 2014Guaranteed Issue. Beginning in 2014, insurers would have been required to accept all applicants for health insurance in the individual market. HIPAA already requires guaranteed issue in the small group market.Adjusted Community Rating. Insurers would have been prohibited from using any factors, including health status and gender, other than limited use of age, geography and tobacco use, in setting premiums.Health Insurance Exchanges. The reform package would allow for the creation of health insurance exchanges at the state level. These exchanges would offer individuals and small groups a forum for purchasing insurance. The components remain unclear, but funding would be available for states to conduct this implementation activity.Subsidies. Low and moderate income individuals below 400% of the federal poverty level would qualify for sliding-scale subsidies that cap the cost of health insurance premiums and cost-sharing at a percentage of their household income.Preexisting Condition Exclusions. Insurers would have been prohibited from imposing any preexisting condition exclusions.Essential Benefits Standards. All insurance coverage would have been required to provide, at a minimum, coverage for specified categories of services and coverage of preventive services without cost-sharing.Limits on Cost-Sharing. Annual and lifetime limits would have been prohibited, and out-of-pocket costs would have been limited to approximately $5,000 per year for individuals and $10,000 for families.Individual Mandate. Most individuals would have been required to obtain health insurance coverage or pay a tax penalty. There would be penalties assessed for those not meeting the mandate. Penalties levels would be based on household income, with low income individuals being exempted.“National Health Expenditures,” (Baltimore, MD: Centers for Medicare & Medicaid Services, January 2010).Written by: Josh Goldberg and Brian Webb, National Association of Insurance Commissioners参考译文：医疗保险改革在许多国家的健康保险市场，一直在努力保持对小企业和个人负担的计划选项。访问中，大多数国家的个别市场的覆盖范围仍然是限制人们的预先存在的条件。此外，大型市场比去年同期的医疗保险费支越来越高增长。小团体市场仍然难以承受，对许多小企业来说，继续提供保费增加覆盖率的几率难以预测。如果没有更多的监管或奖励，以促进公司在市场上进行范围更大的运作，这些问题将继续存在。 许多国会的提议会直接影响健康保险监督和市场形势。然而，在联邦采取行动的情况下，会逼迫各州自行解决这些棘手的问题，这些都将变得复杂起来，带来的政治两极化联邦健康改革的争论以及严重的预算困难，这是大多数州目前面临的问题。国家已经并将继续最新的医疗改革，在过去的几年中,许多州都迎难而上在制定和实施各种各样的改革进行探讨。事实上,大部分的联邦政府的立法,为了改善健康保险在这个国家,如医疗保险可移植性和责任法案1997年,都是建立在成功国家改革。通用的规则的概述健康保险监管实质上是一种混合的联邦和州的监督。一般来说,美国规范健康保险。然而,联邦政府,随着时间的流逝,采取法律、法规的规定,联邦用金包裹自治。今天,大约有36%的健康保险属于国家监管部门管辖。员工退休所得安全法案(ERISA)1974年建立的联邦政府为的调节雇主提供的福利,包括健康保险。美国的权威规范所购买个人保险的用人单位保存。如果雇主不购买保险的选择融资,而不是自己分担风险自己,那么对应的国家法律中，政府也不用交纳州监督。健康保险的可携带性和责任法案(1996年)法案建立了联邦准则最低,主要的规定、小组报道。如果一个国家法律不符合最低标准,那国家法律就形同虚设,联邦政府调控就要起到作用。除了这些联邦优先购买权、国家监督,规范个人和小组的市场和其他方面的私人健康保险。以下部分简要地介绍了州有关管理框架,包括市场调节、商业和操作的疏忽,以及消费者的保护。健康保险市场个人市场。个人(市场是美国。在大多数州,这个市场住着那些个体经营者,或他们的雇主。小组市场。小范围的市场,在大多数州,由雇主和2 - 50名员工。一些国家包括组1(个体户),也可以包括雇主和100名员工。大型集团市场。大群市场是由雇主和雇员太多购买在小范围的市场，属于国家规定。国家要求医疗保险许可运营商可以卖健康保险前国家。在执业医师资格的过程中,国家的背景回顾的所有者和板材、金融业务计划,和另外的信息以确定其是否符合基本状态的要求。国家建立最小为健康保险航空公司偿付能力标准来确保他们有足够的资金来满足他们的义务。保险监管全国协会(州)次助攻立法季度、年度财务报表的审核,以确定所有潜在的问题。访问加以覆盖保证问题。法案建立了国家标准,所有的小型集团计划必须得到保证小雇主可能被否认的报道。一个人“信誉集团范围确定能够个人计划指定为“IPAA-eligible”的状态。所有国家都有法律满足这一最低的标准,而一些州已经扩展保证市场个体的问题。既存的条件限制。排除法案建立了国家标准范围覆盖,使集团存在条件政策,排除覆盖特定疾病相关的关心、残疾、疾病等鉴定的,患者或他们的医生在“回头”期间在消费者购买保险。法案的标准允许为6个月期间,回首限制排除时期到12个月。排除减少一个月期间每月覆盖体面的人们并没有明显的差距在参与研究前。国家会创造一个更严谨,但是并不因此而较不严谨,方法排除既存的条件。高危水池。35个国家创造了高风险池。个人和家庭。一般情况下,消费者必须,却遭到拒绝的报道之前市场个体进入高危池和费用的百分之200上限为个人平均市场。主要的水池评估资助的健康保险载体。依赖的报道。许多州法律要求的承保公司允许参与者家属在购买费用的18岁,有某个年龄。这个要求常被限制未婚的孩子或学校里的孩子们。形式和利率回顾政策形式和率。承保公司须提供政策形式(合同)和保险费率国务院保险。有些州要求批准前的表现形式及/或率可使用;其他人每天需要的表现形式