Could We Have This Debate Before It Is Too Late? -

Is the use of fully insured group health insurance products as stop-loss coverage for group health plans going to remain a viable solution?

The obvious question that follows is: Are State Departments of Insurance Compelled by the Affordable Care Act (ACA) To Limit Fully Insured Health Products to Minimum Essential Benefits?

Short answer is a resounding No. This is an intriguing question which is being hashed out across our land and I am sad to say that most DOIs are getting it wrong. Section 1301, Paragraph (b), 1, A, the ACA is very clear in its definition of a health plan:

1) Health Plans—

(A) In General.—the term ‘‘health plan’’ means health insurance coverage and a group health plan.

Did that come through? “And a group health plan”.

One of the things that came out of the ACA, which I only hear complaining about, is the Medical Loss Ratio (MLR) mandate; 80% of small group (99 and under) and 85% of large group premium dollars must go to fund patient care. This puts fully insured products in the strange position of being underpriced as a stop-loss product.

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