State insurance regulators on Thursday unanimously recommended controversial rules that govern how much insurers must spend on patients' medical care, and they chose not to adopt any of several amendments that consumer advocates had feared would gut key provisions.
The rules, which involve an important part of the new health care overhaul law, now go to Health and Human Services Secretary Kathleen Sebelius, who has final say. Leaders of the National Association of Insurance Commissioners voted after months of meetings and debate that involved industry and consumer representatives. The recommended rules center on the "medical loss ratio," which is how much insurers spend on medical care versus administration and profit.
The health overhaul law that Congress approved in March requires insurers to spend at least 80 percent of their revenue on direct medical care starting next year and to issue rebates to consumers if they fail to hit the target.
During the debate that led to the recommendations, insurers pushed for the broadest possible definition of what constitutes medical spending, including such things as the cost of paying claims, signing up doctors to their networks and running customer service call centers. The final recommendations are narrower, which is what consumer groups had urged.
For example, the commissioners would allow insurers to include many quality improvement costs along with payments to doctors, nurses, hospitals and other providers in their medical expense calculations, but not costs of fraud-control efforts or billing. They also recommended that insurers be able to deduct federal and state taxes, but not the taxes they pay on investment income.
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