Abathengi baye bafumana iibhiliyoni zeeDola kwiMLR
UMthetho woNonophelo ojongene noThathaka, owenziwe ngowama-2010, wenza utshintsho olunzulu kwimimiselo esetyenziswa kwingxelo yomshuwalense wezempilo. Esinye salezo zinguquko kwakuwumgaqo olawula ipesenti yeepriyamu ezinkampani zomshuwalense kufuneka zichithe kwiirejista zeendleko zonyango, ngokuchasene neendleko zolawulo.
Ngaphambi kokuba i-ACA, iinkampani zomshuwalense zikwazi ukubeka izikhokelo zazo.
Iikhoshurensi zaseburhulumenteni zombuso ziza kuhlolisisa i-premium justification ukuba i-insurers ecetywayo, nangona inkqubo yokuphonononga yayingagqibekanga. Kwaye ukuba i-inshurensi yayineendleko eziphezulu zezolawulo, kwakungekho ninzi indlela yokufumana abalawuli okanye abathengi.
Kodwa i-ACA yenze imfuno yokulahlekelwa yonyango (MLR), ecacisa ipesenti eziphezulu zamaphepha-mali angabhawulayo kwiindleko zolawulo. Kwimarike enkulu yeqela, abaqinisekiso-mali kufuneka bachithe ubuncinane ama-85 eepesimenti kwiindleko zonyango kunye nophuculo lwemgangatho wezempilo . Kwiimarike zeqela kunye neencinci, umyinge i-80 ekhulwini. Ngako-ke i-insurers inokuchitha ixesha elininzi kwi-15 okanye i-20 yemali yemali kwiindleko zokulawula (kuxhomekeke ekubeni isicwangciso sithengiswa kwikharityhulam enkulu, okanye kumakethi athile kunye namacandelo amancinci), kunye neyonke imali ye-premium efunyanwa ngu-inshurensi Ukuqokelela kufuneka kuchithwe kwiibango zonyango kunye nezinto eziphucula umgangatho wokunakekelwa kwempilo kwizonyango.
"Iqela elikhulu" ngokubanzi libhekisela kwimigaqo yomshuwalense ethengiswa kubaqeshi abangaphezu kwama-50 abasebenzi. Kodwa eCalifornia, eColorado, eNew York naseVermont, izicwangciso zeqela elikhulu zithengiswa kubaqeshi abangaphezulu kwabasebenzi abangaphezu kwe-100, njengoko i-market small small market inabo iquka abaqashi nabasebenzi abayi-100.
Ziziphi i-MLRs Ngaphambi kokuba i-ACA?
Imithetho ye-ACA ye-MLR yaqalisa ukusebenza ngo-2011. Ngaphambi koko, malunga neyesibini kwi-third of the insurerrs sele beyichitha ininzi yamaprayamamalungu abo kwiimangalo zonyango, kodwa kwakungekho indlela ejongene nayo t.
Kwaye kwahluka kakhulu kwiimarike enye kwenye. Ukuxilongwa koHlolo lwe-Accountability Office, i-77 ekhulwini yabaxhasi bakhulu bee-insuredrs kunye ne-70 ekhulwini yabanini-bhoksi abancinci sele sele bedibana nezikhokelo ezintsha ze-MLR ngo-2010 (ngaphambi kokuqalisa ukusebenza), kodwa kuphela ama-43 ekhulwini kwabagcini-bhintenisi ngabanye bachitha i-80 ekhulwini yentlawulo ye-premium kwiindleko zonyango ngaloo nyaka. Kwaye ngokwemali yeCMS, iipesenti ezingama-45 zabantu abane-inshurensi nganye yemarike yemarike ngo-2010 zahlanganiswa zizicwangciso ezichitha imali engama-25 yeengeniso ze-premium kwiindleko zolawulo.
Kubalulekile ukuba uqaphele apha ukuba ama-7 ekhulwini kuphela aseMerika anikezelwa kwiimarike, ngelixa ama-49 ekhulwini anikezelo lweemarike ezixhaswe ngumqeshi, kubandakanywa nabaqeshi abakhulu nabancinci.
Iindleko zolawulo zihlala ziphantsi xa umgcini-mali unokubambisa ubomi abaninzi ngecebo ngalinye lokuthenga.
Yingakho iimfuno zeMLR zixhomekeke kakhulu kumabharensi amakhulu kunamaqela amancinci kunye nabanini-mkhunga.
Iimigaqo zeMLR zixhaswa njani?
Imithetho ye-ACA ye-MLR iyasebenza kuzo zonke izicwangciso ezikhuselekileyo ngokupheleleyo kwiimarike zeqela, ezincinci kunye neentengiso ezinkulu zeqela, kubandakanywa izicwangciso eziphezulu kunye nezikhulu. Kodwa ayisebenzisi kwizicwangciso zobuqu ezizimeleyo (umkhulu umqeshi, mhlawumbi banokuziqinisekisa, kunokuba bathenge i-coverage yabasebenzi babo; amaphesenti angama-61 abo bonke abasebenzi abaneenkxaso-mali ezixhaswe ngumqeshi zigqitywe phantsi kwe-self-insured cwangciso).
Ngomhla wama-31 kaJulayi unyaka ngamnye, abaxhasi bazisa ingxelo kwiCMS kunye neengeniso zabo ezikhoyo kunye nedatha yeendleko ukusuka kunyaka odlulileyo.
Abaqinisekisi bafunyaniswa ukuba bahlangabezane neemfuno ze-MLR ukuba bachithe ubuncinane ama-85 ekhulwini lama-premium eqela elikhulu kwiinkonzo zonyango kunye nokuphuculwa kwekhwalithi, kunye ne-80 ekhulwini yeqela elincinci kunye nama-premium athengiswayo kwiinkonzo zonyango kunye nophuculo lomgangatho.
Abatshutshisi abangahlangabezananga nala ma thagethi kufuneka bathumele izibhengezo kubaphathi-nkqubo, ngokuqinisekileyo babuyisele ngokubaluleka kwii-premiums eziphezulu kakhulu. Iimfuno ze-MLR zaqala ukusebenza ngo-2011, kwaye ukuhlolwa kwe-rebate yokuqala kuthunyelwe ngo-2012. Ukususela ngo-2014, inani lemali yesaphulelo liye lisekelwe kwi-MLR ye-three-year average insurer, kunokuba nje i-MLR yangaphambili.
I-HHS inokunyanzelisa izigwebo zemali kubanini-mshishini abangabhengezeli iinkcukacha ze-MLR, okanye ezingathobeli iimfuno ze-rebate.
Ngubani Ofumana Iingxabano?
Ngo-2017, abantu abayizigidi ezingama-3.9 bafumana izihlawulelo ze-MLR, ngokuthe ngqo kwiinkampani zabo zomshuwalense, okanye zigqitywa ngabaqeshi babo. Yiyo kuphela i-1.2 ekhulwini yabemi base-United States, ngoko ke abantu abaninzi abafumani izihlawulelo ze-MLR. Ngokuqinisekileyo, i-ACA ye-MLR ilawula kuphela isicelo kwizicwangciso ezixhaswe ngumqeshi kunye nezicwangciso zorhwebo. Ayizicelo kwizicwangciso zeqela ezizimeleyo, okanye kwi-Medicare neMedicaid, enokubambisa i-chunk enkulu yabemi (kodwa kukho imigaqo ehlukeneyo ye-MLR ye-Medicare Benevantage kunye neCandelo D, kunye neenkqubo zozinakekelo ezilawulwa yiMedicaid ).
Kodwa nakwezinye izicwangciso zempilo eziphantsi kwemiyalelo ye-ACA ye-MLR, abaninzi banokuthotyelwa kwaye akufuneki ukuba bathumele ukuhlolwa kweerhafu. Yaye ukuthotyelwa kuye kwaphucula emva kwexesha. Amaphesenti angama-95 abantu abaneempilo zemarike nganye bahlanganiswa zizicwangciso ezidibana neemfuno ze-MLR ngo-2016 (ngokuchasene namaphesenti angama-62 kuphela ngamalungu ngo-2011). Kwimarike enkulu yeqela, iipesenti ezingama-96 zabhalise kwiiplani ezidibana nemithetho ye-MLR ngo-2016, kunye nakwiimakethe zeqela elincinci, iipesenti ezingama-90 zabhalisi zihlanganiswe zicwangciso zeMLR-2016.
Izaphulelo ze-MLR zisekelwe kwi-block yebhanki yonke yebhanki kwicandelo ngalinye lemarike (iqela elikhulu, kunye neqela ngalinye / elincinci). Ngoko akukhathazeki ukuba yeyiphi ipesenti yeepomimenti zakho ezichithwe kwiindleko zakho zonyango, okanye yiyiphi ipesenteji yeprayimari zeqela lakho lomqeshi esetyenzisiweyo kwiindleko zonyango zonyango. Yintoni ebalulekileyo ukuba iyonke xa onke ama-premium e-insurer edibeneyo, kwaye kuthelekiswa nesixa-mali esiqeshwe ngumgcinimarensi kwiindleko zonyango kunye nophuculo lomgangatho.
Kucacile ukuba, akuyi kusebenza ukujonga i-MLR kwizinga ngalinye, ekubeni umntu ohlala enempilo unyaka wonke unokufumana kuphela ama-dollar ambalwa kumabango, ngokumalunga namawaka angamawaka eerandi kuma-premium, ngelixa umntu ogula kakhulu inokuba nezigidi zeedola kwiibango, ngokumalunga nama-dollar ambalwa ama-dollar kuma-premium. Inqaku elipheleleyo le-inshurensi kukukukhupha umngcipheko wonk 'ubani kubantu abaninzi baso-inshurensi, ngoko ke indlela iMLR ilawula ngayo ukusebenza.
Kwimarike nganye, abaqinisekiso-mali abangahlangabezananga neemfuno ze-MLR bazithumele ukuhlola i-rebate ngqo kumnini ngamnye wemigaqo-nkqubo. Kodwa kumakethi axhaswe ngumqeshi (iqela elikhulu kunye neqela elincinci), umgcini-mali uya kuthumela isheke sokuhlawula kumqeshi. Ukusuka apho, umqeshi angakwazi ukwabelana ngemali kubhalise, okanye asebenzise isaphulelo sokunciphisa ama-premiums okanye ukuphucula izibonelelo zabasebenzi.
Iingxowa zeMLR azihlawulwanga, kodwa kukho ezinye iimeko apho zikhona (kubandakanywa neimeko apho ababhalisile abaqeshwe ngabasebenzi bakha ama-premium abo kwimbuyekezo yabo yentela). I-IRS ichaza ukuhlawulwa kwezahlulelo zeMLR apha, kunye nemimiselo emininzi.
Ziphi Iingxaki?
Izahlulelo ezipheleleyo ziphezulu kakhulu ngo-2011 kunokuba ziye zadlulayo kwiminyaka elandelayo, emva kokuba i-insurers isetyenziswe kwimithetho emitsha. Unyaka ngamnye, i-CMS ibhalisisa idatha ebonisa inani lemali yokuhlawula kunye nezaphulelo eziqhelekileyo zamakhaya kwimeko nganye efumana izizaphulelo. Kwiminyaka yokuqala yesithandathu, ukubuyiswa kwe-MLR kubuyile malunga no-3.24 billion kwii-abasebenzisi:
- I-1.1 1.1 yezigidigidi ze-2011 (iirhafu ezithunyelwe ngo-2012)
- Izigidi ezingama-504 ezigidi ngo-2012 (izaphulelo ezithunyelwe ngo-2013)
- Iigidi eziyi-333 yezigidi ngo-2013 (izaphulelo ezithunyelwe ngo-2014)
- Iimali ezingama-469 zezigidi ngo-2014 (izaphulelo ezithunyelwe ngo-2015)
- Izigidi ezingama-397 zigidi ngo-2015 (izaphulelo ezithunyelwe ngo-2016)
- Iimali ezingama-447 yezigidi ngonyaka we-2016 (izaphulelo ezithunyelwe ngo-2017)
Ngo-2017, umntu oqhelekileyo owathola isaphulelo se-MLR wayifumana i-113, kodwa wayehluka ngokubanzi ukusuka kwelinye ilizwe ukuya kwelinye. Abantu baseCalifornia abafumana izizaphulelo bafumana umyinge we-$ 599, ngelixa abantu abali-11 ababengenaso isaphulelo kuzo zonke, kuba bonke abaqinisekisayo kulawo mabandla badibana neemfuno ze-MLR.
Abatshutshisi basebenzisa iinyanga eziliqela ngonyaka ukuqinisekisa ukuba zeziphi iiproyamu zabo ezifunekayo kunyaka ozayo, kwaye ezo zihlomelo ezicetywayo zihlolwe kabini ngamacandelo e-state kunye nakwamanye amazwe. Kodwa amabango ezempilo angakwazi ukuguquka ngokukodwa ukusuka kunyaka omnye kuya kwesinye, kwaye izicwangciso ezenziwa ngabashuseli abahlali zihlala zichanekile. Ngoko ukuhlawula kwe-MLR kuyasebenza njengento yokubuyela emuva, ukuba ngaba abo batshicili baphela bengadingi ukuchitha ii-80 ekhulwini (okanye ama-85 ekhulwini kwiimarike zeqela elikhulu) zeeprayimari kwiindleko zonyango kunye nophuculo lomgangatho.
Ngokomzekelo, ngowama-2017, xa ama-inshorensi ebeka amaxabiso emarike nganye ngonyaka ka-2018, bekukho ukungaqiniseki okukhulu malunga nokuba ulawulo lweTrump luya kuqhubeka lubonelela ngemali yenkxaso-mali yokunciphisa ukwabelana ngeendleko (CSR). Ekugqibeleni, ulawulo luphelile loo mali, kodwa eso sigqibo safika emva kweeveki ezimbalwa ngaphambi kokuqala ukubhaliswa okuvulekile, kwaye amaxabiso amaninzi kumazwe asele asekwe. Ama-insurers akhankanywe kwiimeko ezininzi ukulungelelanisa imilinganiselo yazo kwiintsuku ezikhokelela ekubhaleni, kodwa amaninzi amaninzi sele ecebise abaqhorensi ukuba bazise amaxabiso abo ngokucinga ukuba i-CSR mali iya kugqitywa, kunye neerhafu zokugcina eziza kuphunyezwa ukuba oko gqibela ukuba kunjalo.
Kodwa e-Louisiana, abalawuli baqaphele ngoSeptemba 2017 (inyanga ngaphambi kokuba i-CSR ixhaswe yi-government federal) ukuba ama-inshorensi eburhulumenteni ayifake amazinga ngokusekelwe ekubeni imali ye-CSR iya kugqitywa, kwaye kwakungekho ncwangciso yokulondoloza ukulungiselela ukulungiswa ezo ntlawulo ukuba urhulumente wesigqibo unqume ukuqhubeka nokubonelela ngenkxaso-mali ye-CSR. Endaweni yoko, urhulumente wacacisa ukuba imithetho ye-MLR iya kusetyenziswa ukuyihlenga emva koko, kunye nabhalisi abafumana izizaziso ukususela ngowama-2019, ukuba baphela ukuba babe neenkxaso-mali eziphindwe kabini kwi-CSR (nge-premium ephezulu kunye ne-fineral féderal finance).
Ekugqibeleni, oko akuzange kwenzeke, njengoko inkxaso ye-CSR yachithwa ngokwenene. Kodwa indlela yaseLou Louisiana kule mzekelo ngumzekelo wendlela imithetho ye-MLR ingasetyenziselwa ukuqinisekisa ukuba abathengi ekugqibeleni bakhuselwe kwiimeko apho akuqinisekanga ukuba izibhengezo ziya kugqiba njani ngokuthelekiswa ne-premium income.
Ngaba iziphakamiso zezoMpilo zeMadokhrasi ziza kuguqulwa njani iMithetho yeMLR?
Ngo-Matshi 2018, uSeninkulu u-Elizabeth Warren (D, eMassachusetts) uqalise uMthetho woKhuseleko lwe-Intshumo yeMpilo yabathengi , ekujoliswe ekuzinzeni nasekukhuseleni i-inshorensi yempilo yabathengi. Icandelo lokuqala lomthetho libiza ukwandisa iimfuno ze-MLR kumakethi athile kunye namancinci amaqela ukuya kuma-85 ekhulwini, ebenza ukuba bahambelane neemfuno zeqela ezikhoyo.
Le mithetho ixhaswa ngokubambisana ngabaqela abahloniphekileyo beSenethi, kuquka iMaggie Hassan (eNew Hampshire), uBernie Sanders (iVermont), u-Kamala Harris (eCalifornia), uTammy Baldwin (Wisconsin) kunye noKirsten Gillibrand (eNew York). Kodwa akunakwenzeka ukufumana ukulandelelana kwiNgqungquthela de ukuya kuthi xa ii-democrats zininzi.
Ngoko ke ixesha lokuba, imigaqo ekhoyo ye-MLR iyakuthi ihlale isendaweni. Kodwa uMthetho woKhuseleko lwe-Intshurensi yezeMpilo yabathengi isebenza njengendlela yendlela apho amaDemokhrasi angathanda ukuhamba ukuba abuye abuyele kwininzi, ngoko kuya kwenzeka ukuba sibone imithintelo emandla kumabhorensi kwiminyaka ezayo. Ukucaca, abaninzi bomshuwalense, ngakumbi kwimarike nganye, baye bafumana ii-MLRs ngaphezu kwe-80 ekhulwini kwiminyaka embalwa edluleyo. Abanye baye bangaphezulu kweepesenti ezili-100, ngokucacileyo ezingenakugcinwa kwaye ziyingxenye yezizathu zeprayimesi eziye zanda ngokukhawuleza kumntu-mthengisi-baso-bhankasele abakwazi ukuchitha ngaphezulu kwamabango kunokuba baqokelela kwiiprayimari.
Kodwa kubabatshintshi abathile, ukutshintshela kwimfuneko ephezulu ye-MLR kwiimakethe zeqela kunye namancinci amancinci kuya kubanyanzelisa ukuba baphumelele. Nangona kunjalo, abantu baxela ukuba i-MLR imigaqo ayinakunyanzelisi abaxhasi-mali ukuba bafake uxinzelelo kubaboneleli bezonyango (izibhedlele, oogqirha, abenzi beziyobisi, njl ngokunyuka kweendleko zempilo. Abatshutshisi kufuneka bachithe ubuninzi bee-premiums kwiindleko zonyango, kodwa kubathengi, ii-premiums ziyakwazi ukuqhubeka zikhuphuka kumanqanaba angenakulondolozwa ngaphandle kokuxhaswa kwe-premium.
> Imithombo:
> Amasebe e-Medicare neeNkonzo zeMedicaid. Iziko loLwazi loThengi kunye noLawulo lweNtshuwalense. Ulwaphulo lweMpilo.
> Amasebe e-Medicare neeNkonzo zeMedicaid. Isishwankathelo se-2016 Iziphumo zokulahlekelwa kwezoNyango . Ingxelo kwaye yapapashwa ngo-2017.
> I-United States Ofisi yokuXanduva loRhulumente. IKomiti yeNdwendwe kwiNdlu yezeMfundo kunye nabasebenzi. I-Intshumo Yempilo Yobumfihlo: Izikhombisi Zokuqala Zibonisa ukuba Uninzi lwabatshutshisi abaza kufikelela okanye baphumelele kwiNqanaba elitsha leMiphumo yokuLawula . Oktobha 31, 2011.
> Warren, uElizabeth. Senate.gov. UMthetho woKhuseleko lweNkxaso yoMshuwalense wezeMpilo . Ngenwe ngoMatshi 2018.