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August 27, 2010 

Office of Consumer Information and Insurance Oversight 

Department of Health and Human Services 

Attention: OCIIO-9994-IFC 

P.O. Box 8016 

Baltimore, MD 21244 

To Whom It May Concern: 

On behalf of the American Academy of Actuaries’1

 Benefits and Eligibility Work Group, I appreciate 

the opportunity to provide comments to the Departments of Health and Human Services, Treasury, and 

Labor in response to the interim final regulations (IFR) on the elimination of preexisting condition 

exclusions, the elimination of lifetime limits and restrictions on annual limits, and other patient 

protections. These regulations implement provisions in the Patient Protection and Affordable Care Act, 

as amended by the Health Care and Education Reconciliation Act of 2010 (referred to collectively as the 

Affordable Care Act or ACA) 

To provide a broad perspective on the issues addressed in this interim final regulation, this work group 

includes actuaries representing a cross section of the health insurance market. We would like to offer the 

following comments and requests for clarification related to guaranteed issue for children younger than 

19, annual and lifetime limits, and emergency services. 

Elimination of Pre-Existing Condition Exclusions/

Guaranteed Issue for Children Younger Than 19 

ACA prohibits an insurer from denying claims for children younger than 19 because of preexisting 

conditions. With the issuance of the interim final regulations, the waiver of the preexisting condition 

clause has been expanded to require guaranteed issue for all children younger than 19. In insurance there 

is a material difference between the elimination of the preexisting conditions clause and the guaranteed 

issue of coverage. The elimination of the right to deny claims because of preexisting conditions does not 

mean that an insurer must issue the coverage. Once an insurer issues coverage, however, it cannot deny 

any claims attributable to a preexisting condition. While a guaranteed issue requirement means an 

insurer must issue coverage, an insurer still may deny claims for preexisting conditions—usually for a 

specified period of time. This is most observable in high-risk pools in which individuals must be issued 

coverage, but typically a waiting period exists before claims for preexisting conditions are eligible for 

payment.2

 

                                                           

1

 The American Academy of Actuaries is a 17,000-member professional association whose mission is to serve the public on 

behalf of the U.S. actuarial profession. The Academy assists public policymakers on all levels by providing leadership, objective 

expertise, and actuarial advice on risk and financial security issues. The Academy also sets qualification, practice, and 

professionalism standards for actuaries in the United States. 2

 Kaiser Family Foundation, State High Risk Pool Pre-Existing Condition Exclusion and Look Back Periods. (January 2009) 

http://www.statehealthfacts.org/comparetable.jsp?cat=7&ind=604 
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The interim final regulations have merged these two concepts, resulting in the requirement for insurers 

to guarantee issue coverage to children younger than 19 without any limitations for preexisting 

conditions. This merger materially increases the cost of coverage over the cost of a policy with only a 

preexisting condition exclusion. In addition, this provision creates the potential for significant antiselection (and, therefore, higher future costs) as parents or legal guardian might seek coverage only if a 

child develops a serious health condition. While HHS has indicated that open-enrollment periods can be 

created to mitigate this concern, insurers are not required to coordinate the timing of these openenrollment periods. As such, continuous guaranteed issue could exist, which would discourage the 

purchase of insurance for healthy children. 

Economic Incentives for Anti-Selection 

The combination of preexisting and guaranteed-issue rules may encourage a financially prudent family 

with healthy children to defer purchase of insurance until a child gets sick. As long as there is at least 

one carrier with an open-enrollment period available at any time during the year, and no penalty for 

deferral, then there is an economic incentive to defer purchase of insurance. In addition, with the 

enactment of ACA, parents or guardians of children with existing uninsurable high-cost medical 

conditions will have a higher economic incentive to purchase coverage than those with little to no 

current expected costs for medical conditions. This combination of factors may encourage anti-selection 

and, subsequently, higher claim costs. 

Group Insurance 

Employer Perspective 

In the group insurance market, employer contributions toward dependent coverage can vary significantly 

depending on the size of the employer. It is common for very small employers to contribute only a small 

amount toward an employee’s premium and little or nothing toward the premium for dependents.3

 Under 

ACA, employers may have a financial incentive to encourage an employee, who wants to include a child 

with higher-than-average health care costs on his or her family plan, to waive that child’s group 

coverage. For example, the employer may pay a child’s individual insurance premium on behalf of the 

employee parent/guardian. The employer also may make up any differences in benefits between the 

group policy and the individual policy. Prior to the effective date of the IFR, an unhealthy child could 

not obtain coverage in the underwritten individual market, nor could the child obtain coverage in a state 

high-risk pool if he or she is eligible for group insurance coverage. This concern disappears if 

continuous guaranteed issue is not available in the individual market (e.g., with a limited openenrollment period). 

The incentives for small employers to take the above actions are real, particularly in states in which 

carriers currently have flexibility in determining small group rates based on the aggregate morbidity of a 

particular small group (and, therefore, a small group’s premium can be significantly affected by an 

individual’s claims). The incentives, however, are not limited to small employers. There also would be 

incentives for fully-insured large employers or self-insured groups, that rate on their own claims 

experience, to identify high-cost children and encourage the employee (the parent/legal guardian of the 

higher-cost child) to purchase child-only policies in the individual market. These employers also may 

assist with the premiums. This would lower costs for the employer’s fully insured or self-insured plan. 

                                                           

3

 Kaiser Family Foundation and Health Research and Education Trust, Employer Health Benefits: 2009 Annual Survey. 

(http://ehbs.kff.org/pdf/2009/7936.pdf) 
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The availability of guaranteed issue coverage without preexisting condition limitations in the child-only 

individual market also could result in some employers choosing not to contribute to child coverage. 

Employee Perspective 

If the regulations impose guaranteed issue and no preexisting condition limitations, employees with 

lower-cost dependent children who are currently insured through employer group contracts may have an 

economic incentive to drop coverage for their children (and not seek coverage in the individual market), 

especially if the employee contribution is high. Depending on the structure of the open-enrollment 

period, it is likely that coverage could be available in the individual market if the child becomes 

unhealthy in the future. Employees with higher-cost dependent children will have the incentive to retain 

coverage through their employers, even if the employee contribution is high. The potential combination 

of lower-cost children exiting the employer group pool while higher-cost children remain could exert 

upward pressure on claim costs and premiums in the group market. It is unclear whether this effect of 

anti-selection was considered in the economic impact analysis of the IFR. 

Individual Market 

An individual market that allows coverage for children without required coverage of parents will 

experience the results of anti-selection as children move from the group market. One example of 

circumstances that could result in anti-selection arises from various types of open-enrollment periods: 

If there is a fixed 30-day open-enrollment period each year, the insurance purchaser likely will 

wait until the end of the open-enrollment period to make the purchase if the child is healthy. 

Since the probability of a healthy child incurring high-cost claims in the 60-day period prior to 

open enrollment is very low, the purchaser likely will wait and purchase at the last possible 

minute to save several months of premium. After the open-enrollment period, the individual 

would purchase coverage to avoid a long period without insurance. If insurers are required to 

guarantee the issue of child-only coverage continuously, the insurance purchaser likely will 

delay purchase until an illness or injury occurs, potentially saving years of premium payment. 

 

The consequence of this would be an increase in the average claim cost relative to today’s environment, 

since there will be a reduced number of healthy children covered. The claim costs are likely to increase 

as additional children are insured only when they become unhealthy. The increase in average claim costs 

will necessitate an increase in average premium. This potentially could produce an insurance rating 

spiral—with an increase in premiums, healthier children will drop out of the pool, increasing the cost for 

those remaining and leaving only the highest-cost insureds over time. We believe all scenarios should be 

considered carefully in the development of rules to minimize such unintended consequences. 

Open Enrollment 

HHS has indicated that companies may create open-enrollment periods, if allowed to do so by state law.4

As indicated previously, the presence of open-enrollment periods by themselves can reduce, but not 

eliminate, anti-selection. 

                                                           

4

 Department of Health and Human Services, Questions and Answers on Enrollment of Children Under 19 Under the New 

Policy That Prohibits Pre-Existing Condition Exclusions. (See Question 2) 

http://www.hhs.gov/ociio/regulations/children19/factsheet.html 
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To minimize anti-selective behavior further, certain principles should be applied in determining the rules 

surrounding open-enrollment periods. First, an open-enrollment period should encourage coverage to be 

purchased early, while discouraging any incentive to postpone securing coverage. Particularly, the 

practice of dropping current coverage, but seeking future coverage on a “just-in-time” basis should be 

discouraged. 

 A corollary to this principle is that the frequency and duration of open-enrollment periods must 

balance the need for access to insurance with the need to discourage anti-selection. 

 There will be a need to coordinate the timing of the open-enrollment period(s) among all the 

carriers to avoid a situation in which there is an open-enrollment period occurring continuously, 

which discourages the purchase of insurance for lower-cost children. 

 It may be preferable to have the timing and duration of the open-enrollment period determined 

by a regulatory entity, either at the state or federal level. This is the current policy for Medicare 

Advantage and Medicare Part D, for which there are single, predetermined annual openenrollment periods. 

Second, administration of the open-enrollment period should be a process that minimizes administrative 

expenses and complexities. Simple rules for open-enrollment periods, such as November or December 

of each year, are administratively efficient and inexpensive. Complex rules, such as those based on birth 

dates unrelated to the birth month or on varying lengths of prior periods without coverage, are inefficient 

and administratively expensive. 

Finally, there should be a balance among these two principles to maximize access to insurance while 

minimizing anti-selection. 

 

Third-Party Premium Payers 

Prior to ACA, the vast majority of states allowed carriers and HMOs in the individual market to 

medically underwrite all applicants and accept them as applied or accept them with a higher premium or 

reduced coverage. Some states allowed insurers to decline coverage altogether.5

 

Thirty-five states have created high-risk pools for individuals who either have been denied coverage in 

the individual market or are guaranteed coverage in the individual market as a result of leaving a group 

contract, as allowed under HIPAA. Thirty-one states that have high-risk pools incorporate limited 

coverage for preexisting conditions.6

 

A primary policy goal of policymakers responsible for enacting ACA was to increase access to 

insurance. However, there is the potential for unintended anti-selection that may increase costs in 

addition to those generated by increased access. For example, HHS allows for the purchase of individual 

child-only policies by third parties, specifically, but not limited to, Medicaid and Children’s Health 

                                                           

5

 National Conference of State Legislators, State High-Risk Pools: Participation and Federal Funding, 2010; State 

Enrollment in 2008. Prior to PPACA, five states required guaranteed issue in the individual market: New York, New Jersey, 

Massachusetts, Vermont and Maine. Three other states required guaranteed issue during an open-enrollment period: 

Michigan, Ohio and Virginia. Although there is no statutory requirement, the BC/BS plans in Pennsylvania offered open 

enrollment as insurers of last resort. http://www.ncsl.org/default.aspx?tabid=14329#2010_Pools 6

 Kaiser Family Foundation, State High Risk Pool Pre-Existing Condition Exclusion and Look Back Periods. (January 2009) 

http://www.statehealthfacts.org/comparetable.jsp?cat=7&ind=604
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Insurance Program (CHIP).7 The provision to allow for third-party payers could create the following 

scenarios, which threaten the ongoing viability of the individual child-only market: 

 Government entities will have financial incentives to purchase child-only policies in the 

individual market for their high-cost members. 

 Providers also will have financial incentives, either directly or through affiliated foundations, to 

purchase individual policies to increase their reimbursement levels. 

Prior to ACA, anti-selection generally was managed by underwriting practices. These practices 

precluded insurance from being purchased only after a child became sick. Practically speaking, it was 

difficult for third-party payers to purchase insurance for these children. ACA does increase access, but 

third-party payers may create significant unintended opportunities for anti-selection. 

Given the high cost of claims for newborns of low birth weight, as well as the higher cost of claims for 

children who are unhealthy, insuring a disproportionate share of such children will increase materially 

the average claims of individual child-only policies. This higher average claim cost, potentially 

exacerbated by third-party payer anti-selection over a period of time, has the potential to create a rate 

spiral for child-only policies. 

Despite anti-selection concerns, allowing third parties to purchase child-only insurance contracts may 

provide useful benefits to some segments of the population who have underwriting access—but not 

affordability access. The following practices could minimize anti-selection associated with premiums 

paid by third parties: 

 Prohibit guaranteed access, even in the open-enrollment period, to those children who might 

otherwise be eligible for the group market. 

 Prohibit guaranteed access, even in the open-enrollment period, to those children eligible for 

Medicaid or other similar programs, including high-risk pools. 

 Allow for rescissions when the presence of third-party premium payers is not disclosed on the 

application, and enable carriers to recover any claims paid up until that point from the third-party 

premium payer. 

If carriers believe that they are going to be subjected to material anti-selection, they may elect to 

withdraw from the child-only individual market. This would result in reduced access, reduced insurer 

competition and fewer choices for individuals who need these policies. 

Coordination of Benefits /Overinsurance 

A potential unintended consequence of mandating guaranteed issue without the ability to apply 

preexisting condition exclusions is that, in certain instances, the rules may create a loophole for abuse. 

Carriers’ ability (prior to the IFR) to medically underwrite materially reduces this risk. 

                                                           

7

Department of Health and Human Services, Questions and Answers on Enrollment of Children Under 19 Under the New 

Policy That Prohibits Pre-Existing Condition Exclusions. (See Question 5) 

http://www.hhs.gov/ociio/regulations/children19/factsheet.html 
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In certain instances, current industry practices do not apply coordination of benefits (COB) provisions, 

nor do they require assignment of benefits8 for individual coverage. Imposing guaranteed issue without 

preexisting-conditions exclusions in such an environment could provide individuals with an opportunity 

to collect more than 100 percent of the cost of care if they have multiple policies in force, which may 

lead to abuse. 

For example, an individual purchases and maintains multiple policies for the months in which he or she 

obtains all his or her annual preventive care (covered by each policy at 100 percent), an elective surgery, 

and a few additional and expensive, diagnostic tests. Thereafter, the individual drops all but one policy 

for the months in which he or she anticipates no routine care. 

Industry practices and regulations may need to be changed to eliminate this loophole that could enable 

abuse. Carriers may need the ability to underwrite for and potentially rescind coverage for policyholders 

filing the same claims and collecting under multiple policies. Carriers may need the ability to apply 

COB, and the necessary rules by which to do so, in the individual market. 

Economic Impact 

It does not appear that the economic impact outlined in the IFR took into consideration many of the 

opportunities for anti-selection associated with open enrollments, third-party payers, and COB. It also 

appears HHS assumed any changes in premiums would be spread across the entire individual market, 

including grandfathered and non-grandfathered plans and all contract types. A more realistic result 

would be that any additional costs will be spread only to non-grandfathered plans and only to contract 

types that include a child or children, which is a significantly smaller subset of the entire individual 

market. This will result in materially higher premium increases for those affected policies. 

It also is unclear whether the impact of healthy children leaving employer groups has been considered. 

The prohibition of preexisting condition exclusions and guaranteed-issue regulation for children younger 

than 19, when combined with other requirements such as coverage of dependents to age 26 and the 

insurance mandate that does not become effective until 2014, allows for additional complications not 

addressed in the economic impact. 

Annual and Lifetime Limits9

ACA prohibits lifetime dollar limits on “essential health benefits” for plan years beginning on or after 

Sept. 23, 2010. Plans may impose “restricted” annual dollar limits on essential health benefits until the 

2014 plan year. Beginning in 2014, even restricted annual dollar limits will not be permitted. Although 

not specifically addressed, it appears that these rules apply to both in-network and out-of-network 

benefits. 

Additional Capital Required 

With greater coverage for those in need, which is a positive benefit of the legislation, there is associated 

cost as a result that insurers will have to bear additional risk. The increased liability associated with 

unlimited annual and lifetime claims will require smaller health carriers and many self-insured employer 

plans either to hold additional capital or to purchase reinsurance to mitigate this additional risk. Today’s 

                                                           

8

 Assignment of benefits pertains to the practice of the insurer paying benefits directly to the provider instead of the insured. 9

 Limited-benefit plans and so-called “mini-med” plans are excluded from the scope of the discussion in this section since the 

regulations provide for a process for these types of plans to be addressed separately by HHS. 
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reinsurance market does not cover claims fully that are ongoing across years since coverage is limited to 

a policy or calendar year and is sold on an annually renewable term basis. So, even when companies 

(i.e., small health carriers and self-insured employers) can purchase reinsurance, they likely will not be 

able to fully transfer this risk. 

Impact versus Risk 

The IFR provides an estimate of the number of individuals who are affected (Federal Register, June 28, 

p. 37217). Based on data utilized, the departments’ estimate that 0.033 percent (or 33 for every 100,000) 

of individuals will incur more than $1 million in medical spending in a year. The document develops a 

calculation that 29,000 would incur expenses of at least $4.7 million by the fifth year. The IFR includes 

a discussion of why these estimates may be overstated (Federal Register, June 28, p.37218). 

Our review of the available data suggests that the number of claims exceeding $1 million in a year is 10 

or fewer per 100,000 covered lives.10 For those who had a large claim in one year, generally the claim 

doesn’t recur (i.e., the person recovers or dies). Given these factors, it is estimated that not more than 2 

per 100,000 will incur $5 million of claims, in current dollars, over a lifetime. This results in 

approximately 4,000 individuals with such claims based on the department’s estimate of 203 million 

individuals covered by insurance. With approximately 25 percent of plans providing unlimited lifetime 

coverage as of the 2009 survey referenced, and up to another 25 percent with limits that are higher than 

$2 million a year based on the interim regulation, the impact of the additional limits on the insured 

population is in the 2,500 to 3,000 life range. 

Although the frequency of large claims should be significantly smaller than projected in the interim 

regulation, insurance plans and self-insured employers will have a new severity risk, as they move from 

2013 to 2014, of all claims billed by medical providers, regardless of size. Few claims equal or exceed 

$2 or $3 million in a year, but when such claims occur, there is little ability for the insurance carrier to 

control costs. The unusual claim that exceeds the $2 or $3 million threshold conceivably can result in a 

claim in excess of $10 million or higher. Such an unusual level of claim charges poses a new 

catastrophic claim risk to plans. The risk can be mitigated if the plan has a large capital base or full 

reinsurance coverage. Regardless of how the risk will be mitigated, the market will require more capital 

to effectively offset the risk. 

Coverage or Payment Limits 

In an effort to keep premiums affordable for consumers, insurance coverage available today limits 

covered benefits in various ways. The scope of services covered under these types of limitations differs 

between individual policies and group policies, with individual policies generally having more services 

subject to some type of limitation. Some common examples of annual limits that are applied today 

include the following: 

                                                           

10 Summit Re 2009 presentation at the Actuarial Society of Greater New York (ASNY) stated seven out of 100,000 lives for 

“loosely managed care” had annual claims based on allowable (negotiated) charges exceeding $1 million in 2008. Windsor 

Partners 2010 presentation at April 2010 Self-Insurance Institute of America (SIIA) meeting presented a study of 5.84 million 

lives that had one claim for every 100,000 lives based on allowable (network) charges exceeding $1 million in annual claims 

for 2008-2009 periods. Munich Re Healthcare Summer 2009 Newsletter reported 10 claims per 100,000 had billed charges 

(before negotiated or network discounts) that exceeded $1 million in annual claims in 2008. 2010 HealthMaps Medical Stop 

Loss Manual prepared by Towers-Perrin indicates 8.1 per 100,000 lives with claims exceeding $750,000 assuming a 20 

percent PPO discount.
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 Coverage for specific types of service may be limited to a stated number of visits or days, such 

as 20 or 30 visits per year. This type of limit commonly is applied to such services as 

physical/occupational/speech therapy, chiropractic services, home health services, and number of 

days for skilled nursing facilities. 

 Coverage for specific types of service may be limited to a stated dollar amount per year. An 

example of services to which this type of limit commonly is applied includes durable medical 

equipment and prosthetic devices. Annual dollar amount limitations are also common for mental 

health benefits in small group and individual policies, where allowed. 

 The dollar amount of benefits payable may be limited for a stated condition and episode of 

treatment (e.g., $10,000 or $20,000 for normal maternity is common for individual coverage.) 

 An annual dollar limit may be applied at the policy level. For example, a policy may pay benefits 

until a stated dollar amount has been paid for the year. This type of provision is used rarely in the 

large group market and periodically in the small group and individual market. When used, the 

dollar limit is typically quite high (e.g., $500,000 or $1,000,000). 

Although the regulation allows for restricted annual dollar limits for essential benefits through 2013, and 

no annual dollar limits thereafter, the application of these restrictions is not entirely clear. Wording of 

the regulation only prohibits dollar limits on essential health benefits and is silent as to other types of 

limits (e.g., day, visit, treatment). The regulation also is unclear as to whether the restrictions apply to 

annual limits on essential benefits at the policy level in aggregate, or whether internal limits on 

individual types of service (e.g., physical therapy, devices, etc.) are affected. 

Currently, some of these provisions are more common than others, and the effect that these provisions 

will have on cost varies. For example, removal of annual dollar limits at the policy level will affect 

aggregate costs much less than removal of internal limits on specific services. It is important that any 

rules clearly state what, if any, dollar and visit limits are acceptable to ensure consistency among carriers 

and across states. 

While other interpretations may exist, the following three are the predominate interpretations being 

considered by various insurers and/or state regulatory agencies: 

1. The restriction and eventual prohibition of annual dollar limits applies at the type of service 

level; however, these limits may be converted to an actuarially equivalent day, visit or treatment 

limit. Under this interpretation, dollar limits on specific services would need to be removed or 

converted. For example, a policy that currently contains a $5,000 annual limit on physical 

therapy treatment could be converted to an actuarially equivalent number of visits. This 

interpretation would have minimal effect on cost since this type of conversion could be applied 

to most internal dollar limits and have no effect on policies that already incorporate this type of 

cost containment. 

2. The restriction and eventual prohibition of annual dollar limits applies at the type of service 

level, and these limits may NOT be converted to an actuarially equivalent day, visit, or treatment 

limit. At least one state has taken the position in the past that day, visit and treatment limits are 
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essentially the same as dollar limits. Under this interpretation, neither dollar limits nor service 

limits could remain; a policy that currently contains a $5,000 annual limit on physical therapy 

treatment would need to be removed. While this interpretation would have a significant effect in 

both the individual and group markets, the impact in the individual market would be significantly 

greater, since internal dollar limits are more common. 

3. The restriction and eventual prohibition of annual dollar limits applies only at the policy level, 

and internal limits on specific services may continue to be used to control cost. Under this 

interpretation, only restrictions on the total amount paid for all services covered under a policy 

must be increased and eventually removed. A policy that currently contains a $5,000 annual limit 

on physical therapy treatment may keep the limit in place or, if desired, convert it to an 

actuarially equivalent visit limit. Most policies available today do not have annual limits that 

apply at the policy level. In cases in which annual limits at the policy level are used, the limit 

usually is quite high (e.g., $500,000 or $1,000,000). The effect of this interpretation, therefore, is 

anticipated to be rather low. 

The Commissioner of Insurance for the State of Washington (COI WA) recently posted answers 

to frequently asked questions on the department website pertaining to how annual and lifetime 

limits should be addressed. The COI WA interpretation is that, with the exception of preventive 

services, carriers can “continue to impose benefit-specific annual limits” even for essential 

benefits.11 The COI WA’s rationale for this is that “Requiring carriers to discontinue this 

common practice may compel discontinuation of certain essential benefits prior to 2014 or the 

imposition of premium increases that make coverage cost prohibitive.”12 

In reviewing the impact analysis found in the interim final regulation, the third interpretation may have 

been intent. The departments’ estimate that 8 percent of large employers, 14 percent of small employers, 

and 19 percent of individual market policies impose an annual limit today; this appears consistent with 

annual limits that apply at the policy level. If annual limits on specific covered services were considered, 

these percentages would be significantly higher. Given the uncertainty in the ways this could be 

interpreted, however, a clarification should be provided to clearly state what, if any, dollar (as well as 

day, visit, and treatment) limits are acceptable. 

Emergency Services 

Determination of Insurer Liability for Out-of-Network Emergency Services 

Some carriers impose requirements that network providers be used if the insured is within a certain 

distance (30 miles) of home. In certain cases, an insured may choose to use out-of-network care for his 

or her emergency service despite the fact that an in-network facility is located within this distance. In 

this event, per the IFR, the insurer does not appear to be allowed to apply the higher out-of-network cost 

share provisions and could face resulting higher costs. 

Providers negotiate with insurers on price for their services in a number of ways, ranging from fee-forservice reimbursement at the CPT or revenue code level to bundled payment approaches such as 

Medicare Ambulatory Payment Classes (APCs). As a result, significant administrative burden may be 

                                                           

11 State of Washington Office of the Commissioner of Insurance. 

http://www.insurance.wa.gov/companies/rates_forms/HCRFAQsforfilers.shtml; accessed Aug. 18, 2010. 12 State of Washington Office of the Commissioner of Insurance 
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placed on insurers as each emergency claim may need to be processed under several different provider 

arrangements to determine the median reimbursement amount. When determining the “reasonable 

amount” for out-of-network emergency services, are insurers required to use a specific pricing method 

such as CPT codes or revenue codes, where the highest of the three amounts (Federal Register, June 28, 

p. 37194) is chosen? Or could the charges be calculated at the encounter level and then the highest 

amount selected? 

In addition, many carriers and third-party claim administrators do not currently have the system 

capability to incorporate Medicare pricing into their claim payments. There likely will be additional 

administrative costs and perhaps capital expenditures associated with updating their systems to handle 

Medicare pricing. Because software and training can be expensive, these added costs could be quite 

significant. 

***** 

We would invite the opportunity to discuss any of these items with you at your convenience. If you have 

any questions or would like to discuss these items further, please contact Heather Jerbi, the Academy’s 

senior health policy analyst (202.785.7869; Jerbi@actuary.org). 

Sincerely, 

Karen Bender, MAAA, ASA, FCA 

Chairperson, Benefit and Eligibility Changes Work Group 

American Academy of Actuaries