In preparation for the model's submission to HHS, on Wednesday, the NAIC sent a letter to Secretary Sebelius outlining several factors that will need to be addressed as the final guidelines are implemented.

Issues highlighted in the letter include: steps state regulators will consider when determining whether to seek transitional exemptions, including the potential impact on insurer solvency; the ability of consumers to find easily affordable products in the state should their carrier leave the state market; the potential impact on premiums paid by current policyholders; and the potential impact on consumer access to agents and brokers.

Beginning in 2011 insurers will be required to issue refunds to those they insure if large group plans spend less than 85 percent of their premium income on actual health costs and small group or individual plans spend less than 80 percent.

"State regulators have reviewed input from dozens of consumer groups, regulators, health care organizations, Members of Congress, state legislators, and industry trade groups to help draft NAIC's recommendations to HHS," said Jane L. Cline, NAIC President and West Virginia Insurance Commissioner in a statement. "Throughout the review process, several issues surrounding MLR have been brought to light that are outside the NAIC's purview. We have forwarded those issues to Secretary Sebelius for her consideration.

"We look forward to continued collaborative engagement with Secretary Sebelius and HHS as we implement health care reform in the states," continued Cline.