Hot Issues in Health Care Conference Overview
Explore the complex regulatory landscape of health care in Colorado, covering topics such as market segments, insurance principles, Cover Colorado, trends, and consumer complaints. Gain insights into the challenges and trends shaping the industry.
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Presentation Transcript
2004 Hot Issues in Health Care Conference Colorado s Regulatory Environment An Introductory Overview Susan Gambrill Deputy Commissioner, Consumer Affairs November 12, 2004
Multiple Jurisdictions Federal Government Medicare FEHBP Single employer, self-funded plans HCPF Medicaid Child Health Plan DOI Fully-insured policies issued in Colorado
Complex and Confusing Different rules for different market segments Underwriting Rating Benefit Mandates Different carriers in different market segments Different rules for different types of plans (HMO, indemnity, etc.)
Variety of Regulated Topics Network Adequacy Prompt Payment Marketing practices/disclosures Coverage options (Mandated benefits) Rating requirements Appeals processes Renewability Product specific (dental, LTC, etc)
Insurance Principles - Market Mismatch??? Broad spreading of risk vs. voluntary market Normal risk profile vs. adverse selection (guaranteed issue) Unknown risk vs. anticipated costs (prevention, maternity, etc)
Cover Colorado State s high risk pool Safety net for those uninsurable in individual market Growing in numbers Premiums at 150% of market Various funding sources
Trends Increasing costs/consumer cost sharing Higher deductibles/limited benefits Too good to be true deals Greater chance of federal involvement Healthy risks opting out of insured market
DOI Consumer Complaint Information Handled over 6000 health complaints last fiscal year Recovered over $7.5 million for consumers 56% complaints re claim issues; 13% complaints re underwriting; 8% complaints re marketing; 23% complaints re policyholder services Additional 50,000 telephone or e-mail inquiries
Division of Insurance Metro Statewide (800) 930-3745 (303) 894-7499 Fax (303) 894-7455 www.dora.state.co.us/insurance
