Legislature(2001 - 2002)

01/30/2002 03:20 PM L&C

Audio Topic
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
HB 290-COMPREHENSIVE  HEALTH INSURANCE ASS'N                                                                                  
CHAIR  MURKOWSKI  announced  that  the final  order  of  business                                                               
before  the  committee would  be  HOUSE  BILL  NO. 290,  "An  Act                                                               
relating  to membership  in  the  Comprehensive Health  Insurance                                                               
Number 2011                                                                                                                     
REPRESENTATIVE  ROKEBERG, testifying  as the  sponsor of  HB 290,                                                               
informed the committee that he  became aware of the existence and                                                               
necessity   of   the   Alaska  Comprehensive   Health   Insurance                                                               
Association (ACHIA) during  his time as chair of  the House Labor                                                               
and Commerce  Standing Committee.   He pointed out that  ACHIA is                                                               
the insurer  of last  resort.   The state  is required  under the                                                               
Health  Insurance  Portability  and Accountability  Act  of  1996                                                               
(HIPAA) to  have a  plan such  as ACHIA or  another plan,  a more                                                               
costly plan  as Representative Rokeberg understood  it, available                                                               
for  those who  can't obtain  insurance.   He explained  that all                                                               
businesses  covered   by  the  Employee  Retirement   and  Income                                                               
Security   Act  of   1974   (ERISA),  particularly   self-insured                                                               
businesses  or those  with  larger groups,  are  now exempt  from                                                               
paying their  premium to keep the  ACHIA plan going.    The ACHIA                                                               
plan  is funded  by  an assessment  on the  premiums  of all  the                                                               
health insurance  underwriters in  the state.   The ERISA-covered                                                               
groups, which  he estimated  to be  the bulk  of all  the covered                                                               
lives in the  state, pay nothing towards this program.   This was                                                               
made most acutely aware to the  program when the state decided to                                                               
withdraw their  support, which amounts  to as much as  20 percent                                                               
or  $400,000  plus.    Therefore, the  burden  on  other  private                                                               
insurers in the state was increased.                                                                                            
REPRESENTATIVE  ROKEBERG  noted  his  desire to  keep  Alaska  as                                                               
friendly to the underwriting business  as possible because Alaska                                                               
has  very  few insurers.    He  estimated  that Blue  Cross  [in]                                                               
Washington and Alaska  has at least 50 percent of  the market.  A                                                               
few other  insurers have  a substantially  smaller amount  of the                                                               
market, and therefore Alaska is  a very uncompetitive market.  He                                                               
noted that  in ACHIA's last fiscal  year it took in  $4.5 million                                                               
in guaranteed premiums  from the existing health  insurers in the                                                               
state.   He  explained that  the public  employees and  the other                                                               
large  self-insured people  in the  state aren't  contributing to                                                               
the  health care  plans of  the state,  which he  believes to  be                                                               
wrong.    Furthermore,  he  was   concerned  that  the  [Knowles]                                                               
Administration  allowed the  collective  bargaining  units to  go                                                               
their own way with health insurance.   That action broke down the                                                               
system  of health  care  for all  state  employees and  retirees,                                                               
which could  result in  jeopardizing the  viability of  the ACHIA                                                               
plan  because  of  the  diminishment  of  the  number  of  health                                                               
insurers in the  state, not to mention those  insurers that won't                                                               
enter the state due to the ever-increasing premiums to ACHIA.                                                                   
REPRESENTATIVE ROKEBERG  explained that [HB 290]  simply tries to                                                               
get  all self-insured  employers who  may offer  a major  medical                                                               
coverage  on an  expense-occurred basis  to come  in.   "In other                                                               
words, anybody we can throw ... a  net out and get under ERISA to                                                               
come in,  and then plus the  State of Alaska," he  clarified.  He                                                               
expressed his  belief that the  State of Alaska should  come back                                                               
in and  pay its  fair share.   Representative Rokeberg  turned to                                                               
the administration's indeterminate fiscal  note and noted that it                                                               
has a $3.18 a month assessment  on each individual.  He [assumed]                                                               
that the  aforementioned cost would  be passed on to  every state                                                               
employee,  and  therefore  he  would  be  viewed  as  causing  an                                                               
increase in  the health plan.   He didn't feel that  was correct;                                                               
the State  of Alaska should  pay that and not  pass it on  to the                                                               
Number 1717                                                                                                                     
CECIL  BYKERK,  Chair,   Alaska  Comprehensive  Health  Insurance                                                               
Association, informed  the committee that  he has been  the chair                                                               
of ACHIA  since mid-1994.  He  noted that he works  for Mutual of                                                               
Omaha.   Mr.  Bykerk explained  that [ACHIA]  began operation  in                                                               
1993  and has  gradually grown  over the  past ten  years to  439                                                               
policyholders  at the  end of  2001.   Policyholders are  charged                                                               
premiums that  are higher  than those that  they could  obtain in                                                               
the marketplace if these persons  were insurable.  However, these                                                               
policyholders aren't  charged what it  would take to  support the                                                               
pool because  it would defeat  the purpose  of a high  risk pool.                                                               
The shortfall  is spread across those  insured in the state.   He                                                               
echoed earlier comments that ACHIA is unable to access self-                                                                    
funded plans.                                                                                                                   
MR.  BYKERK explained  that HB  290 attempts  to broaden  ACHIA's                                                               
assessment base, which he believes  to be critical to the success                                                               
of ACHIA in Alaska.   He pointed out that there  is a greater and                                                               
greater burden  on the insured population,  which mainly consists                                                               
of   small  employers   or   individuals.     Additionally,   the                                                               
marketplace  in  Alaska  is  extremely  fragile  [because]  there                                                               
aren't  many carriers  in the  state.   Mr.  Bykerk informed  the                                                               
committee that  the alternative  to ACHIA,  as far  as compliance                                                               
with HIPAA, would be some  other mechanism that would undoubtedly                                                               
be  a guarantee  issue  environment.   Based  on observations  of                                                               
other  states, Mr.  Bykerk said  that such  an environment  would                                                               
likely  result  in a  number  of  carriers withdrawing  from  the                                                               
state.   Therefore, the options  would be further narrowed.   Mr.                                                               
Bykerk said that he is  fully supportive of [HB 290's] particular                                                               
way  to broaden  the assessment  base because  currently all  the                                                               
employees of  self-funded employers in  the state have  access to                                                               
ACHIA.  If such an employee  leaves an employer and has 18 months                                                               
of continuous  coverage, that employee  has the option  of coming                                                               
into  ACHIA  without serving  a  preexisting  condition, and  the                                                               
employee  is  guaranteed  access  to ACHIA's  pool.    Therefore,                                                               
[self-funded]  employers  are  receiving  the  benefit  of  ACHIA                                                               
without contributing, which means  that the burden is transferred                                                               
to the remaining insured population in the state.                                                                               
Number 1471                                                                                                                     
CHAIR  MURKOWSKI  asked  whether   any  other  options  had  been                                                               
identified  beyond broadening  the  assessment base,  as is  done                                                               
with HB 290, or raising the premiums.                                                                                           
MR. BYKERK  pointed out that there  are a number of  ways to gain                                                               
access to  the self-insured employers.   The language  in Section                                                               
1(3)  seems to  leave [the  avenue to  gain access  to the  self-                                                               
insured  employers] open.   He  noted that  there are  approaches                                                               
that aren't based  on premium but rather based  on covered lives.                                                               
Such an approach gains access to  some of the self-insured.  Some                                                               
states use a  general revenue appropriation approach,  but it's a                                                               
"dicey"  issue.   He informed  the committee  that one  state has                                                               
attempted to [impose]  a provider tax, which he likened  to a per                                                               
visit or per head tax.   Unfortunately, such a tax gets labeled a                                                               
"sick tax" and thus isn't well-received.                                                                                        
Number 1343                                                                                                                     
REPRESENTATIVE HALCRO  referred to  the sponsor  statement, which                                                               
states that ACHIA generated about  $3 million of which $2 million                                                               
was   from  contributions   from  members   and  $1   million  in                                                               
contributions  from individual  premiums.   However, the  sponsor                                                               
statement goes  on to  say that  ACHIA paid  out $3.9  million in                                                               
claims.  Therefore, it seems  that ACHIA was left $900,000 short.                                                               
Who would make up that difference, he asked.                                                                                    
MR. BYKERK  answered that there  are some accounting  issues that                                                               
could be  addressed at  a later  time.   He explained  that ACHIA                                                               
tries to keep  the number of assessments down during  the year so                                                               
that administrative  [costs are kept  down].  For  example, ACHIA                                                               
recently sent  out an assessment  for $2 million.   However, it's                                                               
unlikely that $2  million will carry ACHIA through  2002 and thus                                                               
later in  the year ACHIA  will make another assessment,  which he                                                               
estimated  would be  for  $2  million.   Some  of  the second  $2                                                               
million assessment will  be for 2003.  Mr.  Bykerk mentioned that                                                               
the numbers Representative Halcro is using are on a cash basis.                                                                 
Number 1230                                                                                                                     
MR. BYKERK  informed the committee  that for 2001  ACHIA received                                                               
approximately $1.7  million in premiums from  policyholders, paid                                                               
$4.45 million  in claims,  and incurred  administrative expenses.                                                               
[In 2001] ACHIA assessed $3,525,000  of which $400[,000] would be                                                               
allocated to either  the year 2000 or the year  2002.  Therefore,                                                               
ACHIA assessed about $3.25 million on an accrual basis.                                                                         
REPRESENTATIVE HALCRO  related his understanding that  when there                                                               
is a shortage members are assessed for that balance.                                                                            
MR. BYKERK  replied yes.   In further response  to Representative                                                               
Halcro, Mr.  Bykerk agreed that  the $4.4 million paid  in claims                                                               
in 2001  is an increase  of 15 percent  from 2000.   Over ACHIA's                                                               
nine years  of existence, the  program has grown steadily  with a                                                               
few growth spurts.                                                                                                              
Number 1089                                                                                                                     
REPRESENTATIVE ROKEBERG asked when  the state removed itself from                                                               
ACHIA, and what was the premium at that time.                                                                                   
MR.  BYKERK recalled  that  when the  state  removed itself  from                                                               
ACHIA  it  created a  significant  impact  on ACHIA's  assessment                                                               
base.   Although  he  noted  that he  would  have  to review  the                                                               
records, he  agreed with Representative  Rokeberg that  there was                                                               
at least a  20 percent impact when the state  removed itself.  He                                                               
estimated that the impact was probably more like 25-30 percent.                                                                 
Number 1013                                                                                                                     
JACK   McCRAE,    Blue   Cross   Blue   Shield,    speaking   via                                                               
teleconference, recalled  that the  state moved  out of  the pool                                                               
[ACHIA] in 1998.                                                                                                                
REPRESENTATIVE HALCRO inquired as  to the state's contribution at                                                               
the time it moved out of the pool.                                                                                              
MR. McCRAE  referred to a document  that said that prior  to [the                                                               
state leaving], Blue Cross of  Alaska paid about one-third of the                                                               
pool and  [Blue Cross's] share  would increase to  about one-half                                                               
of the  pool.  Mr. McCrae  ultimately said that he  would have to                                                               
obtain more information to answer the question.                                                                                 
Number 0930                                                                                                                     
BOB  LOHR,   Director,  Division  of  Insurance,   Department  of                                                               
Community & Economic Development  (DCED), recalled that the state                                                               
paid $369,000  in 1997.  He  also recalled that the  state became                                                               
self-insured  in  the  middle  of  1998.    Although  there  were                                                               
payments  [to ACHIA]  in subsequent  years,  those payments  were                                                               
lower  because there  were  fewer state  employees  covered.   In                                                               
response  to  Representative  Rokeberg's question  regarding  the                                                               
premium at  the time the state  pulled out of the  pool, Mr. Lohr                                                               
offered  to run  the  numbers  in order  to  determine what  [the                                                               
premium]  would have  been as  a percent  of the  total for  that                                                               
KATIE CAMPBELL,  Actuary L/H,  Division of  Insurance, Department                                                               
of  Community &  Economic  Development, explained  that when  the                                                               
state became self-insured in the  middle of 1997, the assessments                                                               
in 1998  used 1997  data.   Therefore, [the  numbers] have  to be                                                               
reviewed over  a couple of years  because there is half  a year's                                                               
premium  that  was counted  until  the  next  year.   About  $130                                                               
million of  the base was state  employee premium.  At  that time,                                                               
the assessments  were about 30  percent.  After the  state became                                                               
self-insured  [the  assessments] dropped  to  .5  percent of  the                                                               
premium for  all the other insurers.   In the next  year it moved                                                               
to .82 percent of the premium.                                                                                                  
Number 0766                                                                                                                     
MR.  LOHR began  by seconding  Representative Rokeberg's  and Mr.                                                               
Bykerk's comments  regarding the importance and  effectiveness of                                                               
the ACHIA  program.  Nationally,  there is a niche  where certain                                                               
individuals are  unable to obtain  insurance through  the private                                                               
insurance market  because of medical conditions.   Therefore, the                                                               
national approach  has been to  establish programs such  as ACHIA                                                               
to provide  coverage at a  higher cost than the  standard premium                                                               
for  standard insurance.   However,  it's  unrealistic to  expect                                                               
that would cover the entire cost  of the program.  Therefore, the                                                               
statute provided for  an assessment, which is  currently based on                                                               
the  total amount  of premium  for medical  insurance written  by                                                               
health insurers in  the state.  He explained that  as a condition                                                               
of writing  major medical policies  in the state,  [the insurance                                                               
company] must  participate in ACHIA.   As mentioned  earlier, the                                                               
assessments have been  around $3 million per  year, which amounts                                                               
to approximately  1 percent  of the premium.   "It's  expected to                                                               
probably level out somewhat at that $3 million level," he said.                                                                 
MR. LOHR  pointed out that  if the assessment becomes  too large,                                                               
as a percentage  of total premium, it begins  to impact insurance                                                               
decisions by those  that are purchasing private  insurance in the                                                               
market.   One  percent  is probably  reaching  the flinch  point.                                                               
Typically, the  insurers pass ACHIA's  assessment costs  to their                                                               
members.  Therefore,  everyone subject to the  assessment is part                                                               
of  a  group  policy  and  would share  in  the  cost  of  ACHIA.                                                               
However,  HB 290  attempts to  assess self-insured  employers and                                                               
add them  to [ACHIA's]  assessment base  to the  extent permitted                                                               
under  federal law.   The  Department of  Law (DOL)  has reviewed                                                               
this  for  the  [division],  and DOL  doesn't  believe  that  the                                                               
employers  can be  reached under  the ERISA  program.   The ERISA                                                               
program  deals  primarily  with pensions,  as  well  as  employee                                                               
benefits.    "To  the  extent that  the  federal  government  has                                                               
occupied  that  field,  they  have,   in  fact,  preempted  state                                                               
regulation of  those programs," he  explained.   The [division's]                                                               
interpretation, as guided by DOL,  is that the federal government                                                               
has  preempted  the opportunity  to  compel  participation in  an                                                               
assessment.  Therefore,  the legislation would only  [be able to]                                                               
include state  health plans  that aren't  union health  trusts in                                                               
the assessment base.                                                                                                            
MR. LOHR specified that [HB  290] wouldn't include the state plan                                                               
that  covers  all  employees  when unions  have  not  elected  to                                                               
establish their own union trusts.                                                                                               
CHAIR  MURKOWSKI  related  her understanding  that  ASEA  [Alaska                                                               
State  Employees  Association]  wouldn't be  included  [under  HB
MS. CAMPBELL  replied yes, and  noted that basically  the General                                                               
Government  Unit  (GGU) went  to  the  union  trust, as  well  as                                                               
several others.   Therefore, anyone administered  by AETNA [would                                                               
be included under HB 290].                                                                                                      
REPRESENTATIVE  ROKEBERG mentioned  the  possibility of  amending                                                               
MR.  LOHR  informed  the  committee   that  [under  HB  290]  the                                                               
assessment base  would increase from  300 million to  510 million                                                               
if  the  State  of  Alaska's active  and  former  employees  were                                                               
included.  The  state's premium would amount  to approximately 40                                                               
percent, $1.2 million, or $45  per employee per year.  Therefore,                                                               
those  insurance  companies  currently paying  assessments  would                                                               
have their  assessment reduced from approximately  one percent to                                                               
six-tenths of a percent of  their total health insurance premium.                                                               
Mr. Lohr  said that he believes  [HB 290] is a  sound concept and                                                               
worth pursuing, if  it can be done on an  equitable basis.  Being                                                               
equitable is the challenge with the ERISA preemption.                                                                           
MR.  LOHR  recalled  Mr.  Bykerk's   mention  of  an  alternative                                                               
mechanism of funding, the stop  loss coverage.  He explained that                                                               
stop loss insurance  is one mechanism to broaden the  base of the                                                               
assessment,   bring  in   more   premium  to   the  policy,   and                                                               
redistribute the  assessment in a equitable  fashion.  Therefore,                                                               
it  is essentially  a covered  lives formula,  which attempts  to                                                               
take the  number of  individuals covered  by health  insurance in                                                               
various forms  and eliminate  the duplication  in that  count and                                                               
use  it as  the  basis for  assessing  a premium  for  CHIA.   He                                                               
acknowledged  that any  method of  assessment  is fairly  complex                                                               
[and therefore]  there would need  to be a requirement  to report                                                               
covered  lives.   Mr. Lohr  specified the  aforementioned as  one                                                               
suggested revision to HB 290 if that approach was pursued.                                                                      
MR.  LOHR explained  that under  a covered  lives approach,  stop                                                               
loss insurers  would be assessed  on the number of  lives covered                                                               
under  the   underlying  self-insured   or  union   trust  plans.                                                               
Therefore, stop loss  insurers would be assessed  the same amount                                                               
per covered  life as other  insurers, which is  presumably passed                                                               
on to  the insured population.   This  is one mechanism  that the                                                               
[division]  believes to  be more  equitable and  could result  in                                                               
lower premiums for  those already forced to pay  into the [ACHIA]                                                               
program  while reducing  the  impact on  the  insured who  aren't                                                               
directly participating in  the [ACHIA] plan.   In conclusion, Mr.                                                               
Lohr related  his belief that  [ACHIA] is a  ray of light  in the                                                               
attempts to increase the availability  of health insurance to the                                                               
uninsured  in  Alaska.    Any   mechanism  that  can  ensure  the                                                               
continued success of [ACHIA] is well worth examining.                                                                           
Number 0139                                                                                                                     
REPRESENTATIVE  HALCRO  recalled  that [DOL]  has  provided  [the                                                               
division] with an opinion that  a certain percentage of the state                                                               
employees  can't be  reached.   He  asked if  those 8,400  union-                                                               
sponsored  self-insured plans  are  the employees  that can't  be                                                               
MR.  LOHR clarified  that the  opinion says  that [the  division]                                                               
can't reach  the employer.   He explained that ERISA  is designed                                                               
to  encourage  employers to  provide  health  benefits and  other                                                               
insurance benefits to  employees.  When the  national pattern was                                                               
reviewed, there was a wide  degree of variation in the individual                                                               
state  insurance that  was available.    Therefore, [the  federal                                                               
government] decided to do a  federal system that they hoped would                                                               
provide  incentives to  provide the  coverage.   "So,  it is  any                                                               
employer that  is self-insured,  that is  that chooses  to absorb                                                               
the cost  of health  insurance as  part of  what they  provide as                                                               
opposed  to   hiring  an  insurance   company  to   provide  that                                                               
coverage,"  he  said.    If  [the  business]  elects  to  provide                                                               
insurance  through a  private insurer,  as the  state did  before                                                               
mid-1997, then they  wouldn't be subject to ERISA  and thus would                                                               
be subject to the state's jurisdiction.                                                                                         
MS. CAMPBELL  pointed out that  the State  of Alaska plan  can be                                                               
regulated under ERISA.                                                                                                          
TAPE 02-8, SIDE A                                                                                                               
REPRESENTATIVE  ROKEBERG  referred  to  a memo  from  Mike  Ford,                                                               
Attorney,  Legislative  Legal   Counsel,  Legislative  Legal  and                                                               
Research  Services,  regarding  the   ERISA  preemption  and  the                                                               
attorney general's  opinion.   He read  the following  portion of                                                               
the memo:                                                                                                                       
        There has been considerable litigation over the                                                                         
    application   [and]   interpretation   of   the   ERISA                                                                     
     preemption revision.   Some courts have  held that even                                                                    
     private  self-insured  benefit  plans  are  subject  to                                                                    
     state  laws regulating  insurance.    Therefore, it  is                                                                    
     possible  that even  private  self-insured health  care                                                                    
     plans  would have  to participate  in the  state health                                                                    
     care plan as contemplated in this draft.                                                                                   
REPRESENTATIVE ROKEBERG  returned to the  issue of the  stop loss                                                               
coverage.   He asked, "Couldn't we  now, if we could  expand this                                                               
bill, place  it upon  the stop  loss insurance  of some  of these                                                               
other self-insured companies?"                                                                                                  
MR.  LOHR answered  that  he believes  that could  be  done.   In                                                               
further response  to Representative Rokeberg, Mr.  Lohr said that                                                               
he didn't know  that covered lives for the premium  would have to                                                               
be used.   However,  he believes there  are several  [reasons] to                                                               
recommend it as an approach.   In regard to the legal battle, Mr.                                                               
Lohr related his understanding that  the case has been overturned                                                               
by  subsequent decisions  and  thus the  Sixth  Circuit Court  of                                                               
Appeals has  recognized that fact.   Mr. Lohr offered  to provide                                                               
Representative Rokeberg with the agreement in writing.                                                                          
Number 0211                                                                                                                     
REPRESENTATIVE ROKEBERG clarified that  currently the only people                                                               
paying for [the  ACHIA] premium are individuals  with small group                                                               
policies  that  aren't under  ERISA  or  some governmental  self-                                                               
insured program or  a union trust.   In Representative Rokeberg's                                                               
opinion, 70-75  percent of  the people  with health  insurance in                                                               
Alaska  don't  contribute to  the  ACHIA  program, which  is  the                                                               
largest problem.   He asked if Mr. Lohr  conceptually agreed with                                                               
that statement.                                                                                                                 
MR. LOHR answered  that he agreed with  the characterization that                                                               
a  large  percentage  of  Alaskans  aren't  covered  directly  or                                                               
indirectly by the assessment.  In  terms of the impact of that on                                                               
the  private   insurance  market,  Mr.  Lohr   said  he  believes                                                               
Representative Rokeberg  [to be correct].   Mr. Lohr  related his                                                               
belief that  broadening the base  of that assessment would  be in                                                               
the public interest.                                                                                                            
REPRESENTATIVE  ROKEBERG remarked  that he  believes the  cost to                                                               
the  individuals  or small  groups  that  do  go to  those  could                                                               
actually be reduced if this was adopted.                                                                                        
MR. LOHR mentioned that he would  like to leave the Department of                                                               
Administration to testify to the  State of Alaska plan.  However,                                                               
in general he felt that broadening the assessment base would                                                                    
make the ACHIA program stronger and reduce the disincentive to                                                                  
stay covered under private and group health insurance policies.                                                                 
Number 0366                                                                                                                     
REPRESENTATIVE HALCRO inquired as to whether the ability for                                                                    
unions to offer union-sponsored plans was part of a collective                                                                  
bargaining agreement.                                                                                                           
MR. LOHR deferred to the Department of Administration.                                                                          
[HB 290 was held]                                                                                                               

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