Every state regulates the terms and conditions of insurance sold in the state and nearly all tax insurers. States require health insurance policies sold there to include specific benefits, such as mental health services, mammography screening, chiropractic services, and coverage for newborns. States use a variety of methods to monitor health insurers’ solvency, including minimum capital and surplus levels, investment restrictions, and financial reviews. In addition, many states have enacted reforms to improve access and affordability of health insurance for small employers. Prominent examples of these reforms are guaranteed issuance and renewal, portability, and premium rate restrictions. These reforms are intended to address concerns about certain individuals being excluded from coverage or priced out of the market. These individuals include those who change jobs or experience costly medical conditions while in the small employers’ insurance market. Although states regulate health insurance, state regulation does not directly affect 4 of 10 people with private employer-based health coverage. ERISA preempts states from directly regulating employer provision of health plans, but it permits states to regulate health insurers. Of the 114 million Americans with health coverage offered through a private employer in 1993, about 60 percent participated in insured health plans that are subject to state insurance regulation. However, for plans covering the remaining 40 percent—about 44 million people in 1993—the employer chose to self-fund and retain at least some financial risk for its health plan. Self-funding is most common among large employers. Only 11 percent of employees in firms of 100 or fewer employees were in self-funded health plans compared with 34 percent of those in firms of 101 to 500 employees and 63 percent of those in firms of more than 500 employees, according to a 1993 Robert Wood Johnson Foundation survey. As stop-loss coverage with less risk to the employer becomes available, however, more small employers may start to self-fund. The NAIC has adopted a stop-loss model act that attempts to define the levels of risk that can be assumed by stop-loss carriers for determining which state insurance laws should apply. State insurance regulators are concerned that some employers may purchase stop-loss coverage in which the stop-loss carrier assumes most of the risk and believe, therefore, that the plan should be subject to state health insurance laws. Because self-funded health plans may not be deemed to be insurance, ERISA preempts them from state insurance regulation and premium taxation. Although ERISA includes fiduciary standards to protect employee benefit plan participants and beneficiaries from plan mismanagement and other requirements, in other areas no federal requirements comparable with state requirements for health insurers exist for self-funded health plans. Table 1 compares the requirements that fully insured and self-funded health plans must meet. One of the most direct and quantifiable costs that insured health plans incur compared with self-funded health plans results from state premium taxes and other assessments paid by health insurers. Most of the costs associated with taxes result from premium taxes that increase costs to insured health plans by about 2 percent in most states. In addition, states also assess insurers for other purposes, but these assessments are generally small and, in many states, the insurer may receive a credit from its premium taxes for these payments. Most states tax health insurance premiums. State revenues from premium taxes on all types of insurance, including property, casualty, life, and health insurance, totaled over $8 billion in 1993. Premium taxes for commercial health insurers range from 0 to over 4 percent; most states have premium tax rates of about 2 percent. Many states exempt or have lower rates for Blue Cross and Blue Shield plans as well as health maintenance organizations (HMO). In some states insurers receive credits that lower their premium tax rates, such as credits for insurers who are headquartered locally or invest in state securities. In addition, the expense of state taxes can be deducted from insurers’ federal taxes, reducing their net cost. See appendix I for a list of premium tax rates by state and type of insurance. Health insurers may also be liable for paying other miscellaneous assessments collected by the states, including assessments for guaranty funds and high-risk pools. Guaranty funds provide financial protections to enrollees who have outstanding medical claims in the case of an insurer insolvency. In years that monies are drawn from the guaranty funds due to an insurance failure, states assess insurers a fee on the basis of their market share within the state to pay for the guaranty fund expenses. States cap the maximum rate insurers may be assessed in a year, typically at about 2 percent of gross premiums. Except in a few states where a relatively large insurer has failed, however, actual assessments are much lower than the maximum rate. In 1993, actual assessments against life and health insurers for guaranty funds averaged 0.34 percent, and guaranty fund assessments exceeded 1 percent of premiums in only seven states. Most states allow insurers to deduct some or all of the guaranty fund assessment from their premium taxes. Appendix II shows state assessments for guaranty funds and deductions from premium taxes. About half of the states maintain high-risk pools to provide health coverage for individuals denied health coverage because of a medical condition. In 1994, about 100,000 Americans were covered by high-risk pools. Although participants in these plans pay a premium for their coverage, the costs of the high-risk pools exceed the premiums collected. To compensate for the difference in premiums collected and claims paid, 20 states have the authority to assess insurers who participate in the high-risk pool. In 1994, 15 states actually assessed insurers to cover high-risk pool losses. Minnesota, with the largest high-risk pool in the nation, assessed insurers 1.7 percent of their premiums in 1995 to cover high-risk pool losses. Most states with assessments (although not Minnesota) allow insurers to offset at least some of the expense of the high-risk pool assessments from their premium taxes. Appendix III shows state assessments for high-risk pools. Table 2 summarizes the costs to health insurers of the various state taxes. Most insurers and HMOs are likely to pass on the costs of these taxes to their customers through higher premiums. However, their ability to do so depends on such factors as the competitiveness of the market, size of the employer, and insurer’s marketing strategy. The cost impact of mandated benefits varies because states differ in the number and type of benefits mandated. The available studies reflect this cost variation, estimating higher claims costs in states with the most mandated benefits and more costly benefits, such as treatment for mental health and substance abuse. However, the studies are limited because their measurement of costs does not account for certain other cost elements, including administrative costs for multistate employers and a loss of flexibility claimed by employers in designing cost-effective benefit packages. In addition, reported cost estimates often do not measure the incremental cost of adding a mandated benefit to a health insurance package; instead, the estimates represent the fraction of total health insurance claims that are paid for each of the mandated benefits. Furthermore, claims costs may exaggerate the differences in costs between insured and self-funded health plans because many commonly mandated benefits are often covered by employers who self-fund even though they are not subject to state regulation. On average, states have enacted laws mandating about 18 specific benefits. As shown in figure 1, 16 states have over 20 mandated benefits; 8 states have 10 or fewer mandates. Maryland (39), Minnesota (34), and California (33) have the most mandated benefits. In contrast, Idaho has only six mandated benefits; Alabama, Delaware, Vermont, and Wyoming each have eight mandated benefits. States most frequently mandate coverage for preventive treatments, such as mammograms and well child care, or for treatment of mental illness or alcohol and drug abuse. In addition, states often require coverage for some types of providers such as optometrists and chiropractors. States typically mandate that insurers cover specific benefits in all plans sold, but some states merely mandate that each insurer make the mandated service available in at least one plan that it offers. Appendix IV shows how many states have enacted each of 20 commonly mandated benefits. In addition, many states have recently begun considering mandating that health insurance cover minimum postpartum hospital stays. For example, a state may require the insurer to cover 48 hours of hospitalization following a vaginal delivery or 96 hours following a caesarian delivery if recommended by the doctor, although in some states shorter stays may be allowed if they are accompanied by a home visit by a nurse or other medical professional. According to the American College of Obstetricians and Gynecologists, as of July 28, 1996, 28 states have enacted laws requiring coverage for postpartum care. Studies conducted in several states between 1987 and 1993 provide varying estimates of the claims costs associated with mandated benefits. (See table 3.) The Virginia State Corporation Commission, for example, has required insurers to report cost and utilization information annually for each of the mandated benefits in the state. Overall, the commission’s report, the most recent of these studies, estimated that Virginia’s mandated benefits accounted for about 12 percent of group health insurance claims in 1993. An earlier study in Maryland, the state with the most mandated benefits, estimated that mandated benefits represented 22 percent of average claims costs in 1988. In Iowa, a state representing the other extreme, a 1987 study estimated that the potential costs of introducing several commonly mandated benefits would be about 5 percent of claims costs. The differences in the cost estimates reported by the various studies are in part due to the number of mandated benefits included in each state. For example, the studies that reported the highest estimated costs were those for Maryland and Massachusetts, which have more mandated benefits than most states. Thus, these cost estimates cannot be generalized to other states. Although the studies reported varying total costs in different states, they generally agreed that several specific mandated benefits accounted for a large share of the costs. In particular, obstetrical care and mental health care were cited as among the most costly mandated benefits; other commonly mandated benefits, such as mammography screening, account for less than 1 percent of costs. For example, in Virginia, obstetrical care, mental health care, and substance abuse benefits accounted for over half of the total claims costs associated with mandated benefits in 1993. Table 4 lists the costs of individual mandates in Virginia. In some cases, mandated benefits covering services offered by some alternative types of providers, such as nurse midwives, may reduce costs because they substitute for more costly forms of care. Some provider mandates, however, may also increase the demand for services, increasing costs. For example, although chiropractic services may be a less expensive alternative for some treatments, mandating their coverage may also lead to increased use. One limitation of most studies on mandated benefits is that they have examined the cost effect of mandated benefits using the fraction of the total health insurance claims costs paid for each benefit, instead of estimating the incremental cost of adding a benefit to the health insurance package. In addition, the reported cost estimates do not necessarily capture the actual effect on employers’ costs, especially in cases in which all costs associated with a mandate do not occur at the same point in time. For example, one actuary estimated that including in vitro fertilization services in health plans would increase premiums by less than 1 percent. In the case of one self-funded employer, however, the total costs to the employer of in vitro fertilization would be greater than the initial cost of the service because multiple attempts are often required and its use may lead to costly, high-risk pregnancies or multiple childbirths. Moreover, multistate employers note that the variation in state-mandated benefits results in additional administrative cost that is not reflected in the studies’ estimates. Employers that purchase health insurance may need to modify their plans to meet differences in state-mandated benefits. Furthermore, employers are concerned that, to the extent that they must comply with mandated benefits, they lose the flexibility to design the most cost-effective health benefit plan to meet their employees’ needs. Employers and managed health care plans have also expressed concern about the potentially high costs associated with any-willing-provider laws. The actual cost impact of these laws, however, as they have been enacted by states is likely to be limited. Any-willing-provider laws require managed health care plans to accept any qualified provider who wants to participate and is willing to accept the plans’ contract terms. The few available studies have examined only hypothetical results of broad any-willing-provider laws and provide no definitive measure of actual costs of the laws that have been implemented. The actual costs of enacted laws would be more limited than the studies’ estimates because most states have passed versions with narrow scopes. The American Association of Health Plans (AAHP) reported that, as of April 1996, 19 of the 24 states with any-willing-provider laws limit them to particular providers, such as pharmacists, or particular types of managed care plans. Furthermore, any-willing-provider laws have been enacted mostly in states with relatively low managed care penetration. AAHP reported that 24 percent of HMO enrollees are in states with limited any-willing-provider requirements, and less than 2 percent are in states with broad any-willing-provider laws. The actual cost effect of mandated benefits to employers also depends on whether the employer offers a comprehensive or limited health plan, which in turn often depends on the size of the employer. Employers frequently offer many of the commonly mandated benefits, even employers who self-fund and are not subject to the state mandates. In general, large employers are more likely to self-fund their health plans and tend to offer more comprehensive benefits than small employers. For small employers, who typically purchase fully insured health plans and are less likely to offer any health coverage, mandates may impose claims costs for benefits that they otherwise might not have covered. Studies conflict about whether increased costs associated with mandated benefits lead small employers to drop health insurance coverage. Self-funded health plans typically offer many of the benefits commonly mandated by states for fully insured health plans, according to studies. This may be due in part to the labor market, where firms must offer competitive health plans to compete for labor. As shown in figure 2, a KPMG Peat Marwick survey of employer benefits among all firm sizes indicates that self-funded health plans are more likely to offer well child care, outpatient alcohol treatment, outpatient drug treatment, mental health benefits, and chiropractic care than fully insured health plans. This survey also reported similar patterns for other benefits that are not typically mandated, including prescription drugs, adult physicals, and dental benefits. Similarly, a survey of Wisconsin insurers also found that “self-funded health plans provide at least as many of the mandated benefits as insured health plans and in some cases provide more generous coverage.” This result may partially be due to the tendency of large employers to both self-fund and offer more comprehensive benefits. Although self-funded plans often offer the same types of benefits states commonly mandate for insurers, self-funded plans may include features that differ from those required by state mandates. For example, state mandates generally specify a minimum number of days of care that insurers must cover for inpatient mental health care. One employer association indicated that many employers prefer designing more flexible mental health benefits, for example, requiring case management rather than specifying a limited number of days of care. Thus, even though 97 percent of self-funded plans offer inpatient mental health care services, some of these plans would not meet the state requirements for fully insured health plans. Assessing the cost differences between self-funded and fully insured health plans resulting from mandated benefits is difficult. To the extent that self-funded health plans offer benefits that are like state-mandated benefits, their claims costs would not significantly differ because of their exemption from state-mandated benefit laws. For less commonly offered benefits, such as in vitro fertilization, self-funded employers would face additional claims costs if they were required to meet the state mandates. In addition, if employers who self-fund their health plan were required to comply with state mandates, they would lose flexibility in choosing the benefits to offer and in offering a single uniform health plan in many states. State solvency requirements add costs only to the extent that they exceed prudent industry practices a health insurance carrier would follow in the absence of state requirements. States use a variety of methods to monitor health insurers’ solvency, including minimum capital and surplus levels, investment restrictions, and financial reviews. The specific requirements vary both by state and by type of insurance. State laws generally require insurers to maintain a minimum level of capital or surplus to become licensed, but this level is a small fraction of most insurers’ assets. The minimum levels of capital and surplus vary by state and by type of insurance, ranging in 1993 from $200,000 to $5 million. Most insurers have capital and surplus levels that exceed these minimum requirements. For example, Maryland requires insurers selling both life and health insurance to have a minimum of $3.75 million in capital and surplus to be licensed. In comparison, as of December 31, 1994, the actual capital and surplus level for life and health insurers licensed in Maryland averaged $200 million. The cost effect of the minimum requirements can be more significant for small insurers, however. According to data from the Maryland Insurance Administration, 19 percent of life and health insurers licensed in Maryland had less than $10 million in capital and surplus. Although some insurers may need to keep higher levels of capital and surplus to comply with the minimum levels that states require under the NAIC-developed model risk-based capital standards, most insurers also exceed these levels. Under risk-based capital, a level (called the “control level”) is calculated for each health plan based on its unique characteristics. If a health plan’s reserves were to fall below this level, the state is authorized to take control of the insurer. A range of regulatory actions would occur if an insurer were to approach this control level. At 200 percent of the control level, the state requires an insurer to prepare a plan to increase its capital; at the extreme, if the insurer’s capital were below 70 percent of the authorized control level, the insurance commission would have to take control of the insurance company. However, standard industry practices tend to be similar to or exceed these minimum state requirements. For example, a representative of the Health Insurance Association of America told us that 90 percent of insurers in 1995 exceeded 250 percent of the authorized control level for risk-based capital. In addition, a Virginia state official noted that, since Virginia adopted enforcement actions based on NAIC’s risk-based capital formula in July 1995, no insurers have fallen below the level where state standards would require action. Blue Cross and Blue Shield plans have different requirements under state laws. For example, many states set target capital and surplus levels for Blue Cross and Blue Shield health plans to ensure that they have sufficient funds to cover, for example, 1 or 2 months of claims. Furthermore, to maintain their nonprofit status, some states require that Blue Cross and Blue Shield plans’ surplus not exceed a target level, such as 7 months’ claims. In addition, states restrict how insurers invest their funds, potentially imposing an opportunity cost on insurers who might otherwise invest in higher yielding assets. These investment restrictions vary by state, but in general states regulate the type and amount of assets in which health plans invest to diversify insurers’ investments and minimize their risk. For example, many states limit the amount of funds that a health insurance carrier may invest in certain types of investments, such as common stocks and foreign securities, with potentially higher return rates than other permitted investments. The risk associated with these investments is also greater, however, so the insurer could get a lower rate of return than with permitted investments. An insurer could even lose money, possibly damaging its solvency. Furthermore, actuaries note that investments typically provide a smaller share of income to health insurers than other types of insurance such as life insurance. States’ oversight of health insurers’ solvency may also add administrative costs to insurers who must comply with reporting and review requirements, but industry officials note that such costs are difficult to quantify. The administrative costs include preparing audited financial statements and actuarial analyses for state review, functions insurers would likely perform anyway. States require insurers to report financial information using NAIC’s accounting standards, however, which differ from generally accepted accounting principles in their valuation of assets. In some cases, this may require an insurer to maintain two sets of accounting data, but insurance company executives we spoke with said this is a marginal additional cost. The costs of actuarial certification vary by type of insurance. Insurers selling only health coverage may prepare a simplified actuarial certification that requires few resources. Insurers selling health and life coverage must prepare a more extensive actuarial certification that would be more costly. One insurer, however, noted that the information developed for the actuarial certification provides the insurer with valuable information on the adequacy of the insurer’s reserves for meeting anticipated costs. Finally, many states charge the insurer for the costs of on-site financial examination, which typically occur once every 3 to 5 years. The costs of these exams vary depending on their length and complexity, but one state reported that the cost can be as high as $1 million for a complex review of a large insurer; less complex ones may cost less than $100,000. Most states have recently passed legislation designed to improve portability, access, and rating practices for the small employer health insurance market. It is too early to assess the cost effects of these reforms definitively because most available information is anecdotal. Moreover, even if more systematic data were available, isolating the effect of small group reforms from other factors would be difficult in the currently dynamic health care market. The small group reforms include provisions to help ensure that (1) employees who want health insurance coverage will be accepted and renewed by insurers; (2) waiting periods for preexisting conditions will be relatively short, occur only once, and be based only on recent medical history; (3) coverage will be continuous and portable, even when an individual changes jobs or the employer changes insurers; and (4) wide variation in premium rates will be narrowed to fall within state-specified ranges. In an earlier report, we identified 45 states that passed legislation between 1990 and 1994 regulating the small employer health insurance market (typically fewer than 25 or 50 employees). We also noted that the specific state requirements vary both by state and from the NAIC model act. The available evidence on states’ early experience with small group reform is mostly testimonial, anecdotal, and often contradictory. Following are examples of some of this evidence. The Colorado Insurance Division reports that small employer reforms, including guaranteed issue and rate restrictions, have moderated premium increases and increased the number of individuals covered by small group health plans. Some initial reports on New York’s experience stated that insurers left the state and premiums increased. Subsequent reports, however, have questioned the extent of these problems. Furthermore, state officials note that most changes occurred in the individual market rather than the small employer market and resulted from other factors, particularly the financial status of the state’s largest insurer. Minnesota and Colorado officials point to the decline in enrollment in their high-risk pools as evidence of the success of small group reforms in making private health coverage more available. Washington’s reforms, which were partially repealed before implementation, resulted in a surge in high-cost, high-risk enrollees that has led insurers to warn of high premium increases and their potential withdrawal from the state. Maryland officials asserted that in the first year of implementing small employer reforms competition in the small group health insurance market has increased and premiums have declined, but they acknowledged that data on premiums before the reforms were sparse. As these examples illustrate, the results across states are not consistent or generalizable to other states’ experiences. Furthermore, even within the states noted above, conflicting views exist about the success or failure of the small group reforms. Some states have specifically designed their reforms to minimize potential cost increases. For example, the task force that developed Maryland’s reforms designed the benefits package to cost less than 12 percent of average wages in Maryland. Ohio state officials scaled back their original reforms after receiving estimates that they could increase costs. As a result, Ohio enacted less generous requirements for guaranteed coverage. In addition, because the private insurance market has been changing rapidly, the effect these reforms have had on health insurance premiums is difficult to isolate. Besides the small employer insurance reforms, factors affecting insurance premiums include nationwide declines in the growth rate of health care costs, the growth of managed care, changes in health benefits, and the expansion of Medicaid coverage. Small group reforms may also have redistributive effects, with some enrollees facing increased costs while others face reduced costs, making the net effect unclear. Changes resulting from small group reforms may take several years to play out fully. Finally, the paucity of data preceding the enactment of reforms may hamper before-and-after comparisons of insurance premiums. State requirements on health insurance and their effects raise two questions: who is affected directly, and what factors determine the size of the requirements’ cost impact? Under the ERISA statute, state governments cannot tax or regulate self-funded plans established by an employer who bears most of the financial risk. By contrast, states continue to have authority to tax and regulate health insurance. As a result, enrollees in insured health plans have the benefits associated with state regulation but also bear an additional cost relative to enrollees in self-funded health plans. This cost differential can differ considerably by state. Specifically, state taxes on health insurers raise the costs of fully insured plans by about 2 percent in most states, with the actual level determined by state tax rate and type of health plan. In addition, the extent to which mandated benefits and solvency requirements raise costs differs by state, depending upon the scope of state laws. Furthermore, the extent to which a cost differential between self-funded and insured health plans would be apparent depends on whether state regulation results in a change in employers’ and insurers’ behavior. At the extreme, for health plans that provide comprehensive benefits and maintain surpluses exceeding state minimum requirements, the cost differential may be nonexistent. The burden of state requirements on large versus small employers depends on the employers’ use of self-funding. Because large employers’ health plans are predominantly self-funded (and outside the states’ purview) and small employers generally purchase health coverage from private insurers, the costs associated with state requirements fall largely on small employers. But this may be changing. Some small employers are also beginning to self-fund, partly to avoid state regulation and taxation of their health plans. Whether this trend will continue, and at what rate, is unclear. NAIC officials provided us with comments on a draft of this report. They pointed out that although the costs associated with state requirements are accurately described, the benefits to plan participants are addressed only to a limited extent. We acknowledge that participants benefit from many state requirements. As noted earlier, our ERISA report more comprehensively describes the state and employer perspectives on the implications of ERISA preemption of state regulation. As agreed to with our requester, our primary focus in this report was to provide additional information on the costs associated with these state requirements. In addition, NAIC officials noted that the report could also address “the costs that employers and employees might face when covered through ERISA-governed plans.” Indeed, ERISA requirements, such as reporting, disclosure, and fiduciary responsibilities, may have associated costs. As noted in the report, however, these costs are borne by all ERISA-governed plans, including both fully insured and self-funded health plans. Thus, they do not lead to a differential in costs between fully insured and self-funded health plans in the way that state requirements applying only to fully insured health plans may. NAIC officials also provided technical comments, which we incorporated where appropriate. As agreed with your office, unless you publicly announce its contents earlier, we plan no further distribution of this report until 30 days from the date of this letter. At that time, we will send copies to interested parties and make copies available to others upon request. Please call me on (202) 512-7114 if you or your staff have any questions about this report. Other major contributors are listed in appendix V. Health insurers (percent) Blue Cross and Blue Shield plans (percent) HMOs (percent) (continued) Health insurers (percent) Blue Cross and Blue Shield plans (percent) HMOs (percent) 0.75 aaTax assessed on subscriber fees. bbPay insurance commission maintenance assessment of no more than 0.1 percent of premium, with a minimum of $300. ccAdditional fee assessed for Department of Insurance operations, not to exceed 0.125 percent of receipts. ddHMOs pay franchise tax of 7.9 percent. Assessment cap (percent) Actual assessment, 1993 (percent) Percent offset from premium taxes (continued) Assessment cap (percent) Actual assessment, 1993 (percent) Participants (Dec. 31, 1994) Michael Gutowski, Assistant Director, (202) 512-7128 John Dicken, Senior Evaluator, (202) 512-7135 Carmen Rivera-Lowitt, Senior Evaluator, (202) 512-4342 The first copy of each GAO report and testimony is free. Additional copies are $2 each. Orders should be sent to the following address, accompanied by a check or money order made out to the Superintendent of Documents, when necessary. VISA and MasterCard credit cards are accepted, also. Orders for 100 or more copies to be mailed to a single address are discounted 25 percent. U.S. General Accounting Office P.O. Box 6015 Gaithersburg, MD 20884-6015 Room 1100 700 4th St. NW (corner of 4th and G Sts. 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Summary: Pursuant to a congressional request, GAO provided information on the costs of state health insurance requirements, focusing on: (1) premium taxes on insured health plans; (2) mandated health benefits; (3) financial solvency standards; and (4) state health insurance reforms affecting small employers. GAO found that: (1) state health insurance regulation imposes requirements and costs on third-party health plans, but not on employers' self-funded health plans; (2) state premium taxes and other assessments for guaranty fund and high-risk pool fees, are the most direct and quantifiable costs on insured health plans; (3) the extent to which these requirements increase insured health plans' costs varies by state because of differences in the nature and scope of state regulation and plans' operating practices; (4) most states mandate that insurance policies cover certain benefits and providers that might not otherwise be covered; (5) costs are higher in states that mandate more costly benefits; (6) most self-funded health plans offer many of the same mandated benefits, but these plans would lose flexibility in offering uniform health plans across all states; (7) state solvency standards have a limited potential effect on plan costs, since most insurers maintain capital and surplus levels that exceed state minimum requirements and typically perform tasks similar to state reporting requirements; and (8) the cost implications of states' small employer health insurance reforms are unclear because of incomplete cost data and the difficulty of isolating the impact of such reforms.