You asked for the following information regarding reporting requirements for health insurance companies and health maintenance organizations (HMOs):

1. what types of information must these insurers report to the state, e. g. , denial rates, medical loss ratios, company financial information, and pay for chief executive officers;

2. when are they required to report this information and how is the information reported; and

3. which types of information are considered proprietary and which is considered public.

SUMMARY

The law, notably CGS §§ 38a-478c and 38a-202, imposes extensive reporting requirements on health insurers. There are overlapping reporting requirements, depending on how the insurer is organized. In the case of managed care organizations (MCOs), which include HMOs as well as health insurance companies, the law requires the companies to report annually by May 1^st on, among other things:

1. complaints related to providers and quality of care,

2. decisions related to patient requests for coverage,

3. the proportion of prior authorizations denied and other prior authorization statistics, and

4. medical loss ratios.

In addition, MCOs must report on the types of financial arrangements or contractual provisions they have with hospitals, utilization review companies, physicians, preferred provider networks, and other health care providers. These include fee-for-service, risk-sharing, or capitated risk arrangements.

MCOs must report annually, by July 1^st, all data required by the National Committee for Quality Assurance (NCQA) for its Health Plan Employer Data and Information Set (HEDIS). HEDIS consists of 71 measures in eight areas that look at the effectiveness of and access to care, among other things.

The information contained in these annual reports is available to the public. The Insurance Department publishes some of the information in the reports, including denial rates and data on quality of and access to care in its annual A Comparison of Managed Care Organizations in Connecticut (http: //www. ct. gov/cid/LIB/cid/mancare1. pdf). However, provider fee schedules are proprietary.

In addition to the above requirements, insurers, HMOs, and other “health care centers” must annually report on their financial condition by March 1^st. The report provides detailed information on the companies (1) assets, investments, and liabilities; (2) capital and surplus; and (3) revenues and expenses. This information is available to the public. More generally, all Connecticut insurers must report to the department by this date on their “risk based capital” (RBC).

There are additional reporting requirements for insurers that (1) provide Medicare supplement coverage, (2) offer policies for care in cancer clinical trials, and (3) offer coverage to small employers.

The state does not require insurers to report salaries for their chief executive officers. However, the federal Securities and Exchange Commission requires publicly traded companies to report on pay and other compensation of their senior executives.

REPORTING REQUIREMENTS FOR MCOS

Annual Reports

Under CGS § 38a-478c, each MCO must submit a report to the insurance commissioner by May 1 annually on its quality assurance plan. The report must include information on (1) complaints related to providers and quality of care, (2) decisions related to patient requests for coverage, and (3) prior authorization statistics. Statistical information must be submitted in a way that permits comparison across plans.

This information must include:

1. the ratio of the number of complaints received to the number of enrollees;

2. a summary of the complaints received related to providers and delivery of care or services and the action taken on the complaint;

3. the proportion of prior authorizations denied;

4. the number of utilization review determinations made by or on behalf of a MCO not to certify an admission, service, procedure or extension of stay, and the denials upheld and reversed on appeal within the MCO's utilization review procedure; and

5. the percentage of employers or groups that renew their contracts within the previous 12 months.

In addition, the MCO must provide:

1. a model contract that contains the provisions in contracts between the MCO and preferred provider networks and participating providers in Connecticut;

2. at the commissioner's request, a copy of any individual contracts between such parties (the contract may withhold or redact proprietary fee schedule information);

3. a written statement of the types of financial arrangements or contractual provisions that the MCO has with hospitals, utilization review companies, physicians, preferred provider networks and any other health care providers including fee-for-service, risk-sharing or capitated risk arrangements.

4. information the commissioner considers necessary to complete the consumer report card (CGS § 38a-478l); and

5. a summary of the procedures the MCO uses to credential providers.

The information required for the scorecard may include, as requested by the commissioner:

1. the organization's characteristics, including its model, its profit or nonprofit status, its address and telephone number, how long it has been licensed in Connecticut or other states, its number of enrollees, and whether it has received any national or regional accreditation;

2. any change in a plan's rates over the prior three years, its medical loss ratio or percentage of the total premium revenues spent on medical care compared to administrative costs and plan marketing, how it compensates health care providers, and its premium level;

3. a description of services, the number of primary care physicians and specialists, the number and nature of participating preferred provider networks and the distribution and number of hospitals, by county;

4. utilization review information, including the name or source of any established medical protocols and the utilization review standards;

5. medical management information, including the provider-to-patient ratio by primary care provider and specialty care provider, the percentage of primary and specialty care providers who are board certified, and how the medical protocols incorporate input as required by law;

6. the quality assurance information required to be submitted by law;

7. the status of the organization's compliance with the law's reporting requirements;

8. whether the organization markets to individuals and Medicare recipients;

9. the number of hospital days per thousand enrollees; and

10. the average length of hospital stays for specific procedures, as requested by the commissioner.

The above information must be consistent with the data required by the National Committee for Quality Assurance (NCQA) for its Health Plan Employer Data and Information Set (HEDIS). The commissioner may accept electronic filing for any of these requirements.

By July 1 annually, the MCOs must report all data required by the NCQA for HEDIS. Table 1 provides examples of these areas and measures.

Table 1: Measures Included in HEDIS

If an MCO does not provide this information for HEDIS, it must provide equivalent data as the commissioner requires by regulation. The commissioner must find that these requirements have been met if the managed care plan has received a one-year or higher level of accreditation by NCQA and has submitted the HEDIS data.

Much of the information required in the reports is used to prepare A Comparison of Managed Care Organizations in Connecticut, which the department prepares annually. This document has information on quality of care measures, utilization review data, and member satisfaction survey results. It also has general information about each MCO, such as the hours it customer service telephones are staffed and the organization's level of NCQA accreditation.

Related Provisions

Under CGS § 38a-47, any MCO that fails to file the data, reports or information required by the insurance laws must pay a late fee of $ 100 per day for each day from the due date of such data, reports or information to the date of filing. The Insurance commissioner gives each MCO that files incomplete data, reports, or information a date by which to remedy the incomplete filing and pay the late fee starting from the new due date.  On June 1 annually, the Insurance commissioner must submit a list of MCOs that have failed to file the required data, reports, or information to the governor and the Public Health and Insurance committees.

FINANCIAL REPORTING FOR INSURERS

CGS § 38a-202 requires HMOs and other health care centers to file annually, by March 1^st, a statement verified by at least two of its principal officers showing their condition as of the preceding December 31^st. The report must be in a form and contain the information as the commissioner prescribes. CGS § 38a-219 imposes the same requirements on nonprofit medical services corporations.

The reports are very detailed, providing information on the companies (1) assets, investments, and liabilities; (2) capital and surplus; (3) revenues and expenses; and (4) cash flow, among other things. For example, the description of the company's assets provides specific information about its stock, bond, and real estate holdings as well as cash. The report also analyzes the company's operations by line of business (e. g. , comprehensive insurance vs. Medicare supplement policies).

Prior to this session, CGS § 38a-53 required all insurers and health care centers doing business in Connecticut to annually file financial statements by March 1^st and audited financial reports by June 1^st with the insurance commissioner. PA 07-225 (1) limits the annual reporting requirements to domestic and foreign companies (insurers organized under Connecticut and other state's laws, respectively), (2) requires the financial statements to be complete when filed, and (3) requires the companies to electronically file the statements and reports with the National Association of Insurance Commissioners (NAIC). Domestic companies that file on time with NAIC must still submit paper copies to the commissioner, but foreign companies do not have to.

CGS § 38a-53 also requires that the March 1^st report include a certification by an actuary or reserve specialist prepared in accordance with regulations adopted by the commissioner. Under the regulations (Conn. Agency Regs. § 38a-53-2), the opinion must address the adequacy of the company's liability reserves. These requirements do not apply to companies with less than $ 1 million in written premiums or fewer than 1,000 policyholders during a calendar year.

By law, the commissioner may require an insurer or health care center to file quarterly financial statements, and in practice the department does. Under PA 07-225, if the company electronically files the reports with NAIC on time, then it does not have to give the commissioner paper copies.

Under CGS § 38a-72, all Connecticut insurers must report to the department by March 1^st on their “risk based capital” (RBC). In the case of health insurers, the RBC must account for (1) the risk with respect to the insurer's assets, (2) the risk of adverse insurance experience with respect to the insurer's liabilities and obligations, (3) the insurer's interest rate risk and (4) other relevant risks as determined by the department (Conn. Agency Regs. § 38a-72-2). Depending on the insurer's level of capitalization, the department can require it to file additional reports and corrective action plans. The information in these reports and plans, to the extent it goes beyond the company's annual filings, is generally considered confidential.

OTHER REPORTING REQUIREMENTS

Under CGS § 38a-481, an insurer that provides Medicare supplement coverage must have its Connecticut or nation-wide loss ratio results, as the case may be, audited for each experience period by a certified public accountant or a member of the American Academy of Actuaries, at the insurer's expense. The audit must be done in the second quarter of the year following the end of the experience period and the audited results must be reported to the Insurance commissioner by the June 30^th following the end of the experience period.

Under CGS § 38a-504, any insurer or health care center with coverage policies for care in cancer clinical trials must submit the policies to the Insurance Department for evaluation and certification. The insurer or health care center must report annually, in writing, to the department that there have been no changes in the policy as certified by the department. If there has been any change in the policy, the insurer or health care center must resubmit its policy for certification by the department.

Under CGS § 38a-567, insurers offering coverage to small employers are subject to separate requirements. These include demonstrating that their rating methods and practices are consistent with accepted actuarial assumptions and principles. They must report to the department on their compliance with the requirements by March 15^th annually. Except for violations of the law, the information in these reports is considered confidential.

KM: ts