The Office of the Health Care Advocate represents Vermont consumers in health insurance rate review cases. Health insurance rate review cases start when an insurance carrier in Vermont wants to change the amount they charge policyholders for an individual or small group health insurance plan.
The HCA’s main concern in these cases is whether the proposed rate change is affordable for the consumers.
When an insurance carrier submits a rate filing, HCA attorneys review the filing. In addition to looking at affordability, the HCA assesses whether the proposed rate change:
- promotes quality care
- promotes access to health care
- protects the insurer’s ability pay claims
- is not unjust, unfair, inequitable, misleading, or contrary to law and
- is not excessive, inadequate, or unfairly discriminatory
Reviewing the Filing
For each rate review case, the HCA begins by gathering information on the filing from the carriers and from the Department of Financial Regulation. The HCA may submit questions to the Green Mountain Care Board (the Board) for the insurance carriers to answer. The Board decides whether or not to require the carriers to answer the questions.
Many “factors” make up the rate review proposal including medical costs, pharmacy costs, and administrative costs. The HCA uses the information it has collected to assess each factor. If the filing is very complicated, the HCA may hire an actuary (an expert in mathematics and statistics) to review the filing and advise the HCA.
Representing the Public
If the HCA finds that the rate the insurance carrier asks for is not affordable for Vermonters, the HCA participates in the rate review hearing or submits written arguments to the Board. The HCA attorneys say why the proposed rate should be lower and ask the Board to either modify or reject the proposed filing.
If the Board rules against the HCA, the HCA can choose to appeal the decision.