AHIP Statement on Medical Loss Ratio (MLR)

August 17, 2010

Robert Zirkelbach
(202) 778-8493

AHIP Statement on MLR


Washington, D.C. – America’s Health Insurance Plans (AHIP) President and CEO Karen Ignagni released the following statement on the MLR blanks proposal approved today by the National Association of Insurance Commissioners (NAIC):

“The NAIC is conducting a transparent and thorough process as it develops the MLR definition, but the current proposal could have the unintended consequence of turning-back-the-clock on efforts to improve patient safety, enhance the quality of care, and fight fraud.  Preserving patients’ access to high-quality health care services is essential if the key goals of health care reform are to be achieved.”

AHIP letter to NAIC on MLR
Last week, AHIP sent a letter to the NAIC on the MLR calculation which urges the NAIC to:

  • “structure the quality framework in a way that allows for the recognition and encouragement of new quality and care improvement initiatives and does not limit permissible programs to those that are currently in the market today.”

  • “reconsider the exclusion of fraud prevention and detection because of its importance to the vital and universally recognized goals of improving health care quality and patient outcomes. Currently, retrospective review is excluded, yet it is a key tool in targeting the dangerous overutilization of services, falsification of medical records, and medical identity theft.”

  • “reconsider the exclusion of costs associated with the ICD-10 implementation. The effort to convert to ICD-10 codes will improve the ability of health plans to share clinical data among clinicians for quality improvement and care coordination activities, thereby promoting a better understanding of diagnoses and procedures at institutional settings of care to allow better treatment and quality improvement.”

  • “re-evaluate the exclusion of concurrent utilization review and the implications this will have on programs designed to improve patient safety and to assure that consumers receive the right care, at the right time, and in the right place. These tools play an important role in addressing growing concerns over variations in imaging use across geographic regions and the potential overuse of imaging services.”

  • “ re-evaluate the exclusion of individual coverage from the wellness and health promotion guidance. The new legislation envisions a transition to wellness-centered care and calls for a pilot wellness program in the individual market. Therefore, it would appear to be inconsistent to prohibit incentives from being offered to consumers purchasing coverage on their own at the same time they are offered to employers in small and large groups.”

  • “adopt a standard methodology to address needed MLR transition rules to promote stability of health plan choices in the individual and small group markets and avoid a potential disruption of coverage for millions of Americans prior to implementation of the 2014 market reforms.”


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