Insurance Market Reform

With the proliferation of narrow network plans on the new marketplaces, consumers are being steered to plans that offer lower prices but limited choice. Insurers may offer narrow network plans to attract price-sensitive consumers who are willing to tradeoff network breadth for less costly premiums. Yet, anecdotal evidence suggests that the resulting provider networks may be narrower than expected, leaving consumers vulnerable to the financial burden of out-of-network care. This free webinar on May 19 at 1:00 p.m. EDT will address the potential policy responses to the growth of narrow network plans and will identify where more evidence is needed to inform researchers and decision makers.

Health plans with relatively narrow provider networks have generated widespread debate, mainly concerning the level of regulatory oversight necessary to ensure plans provide consumers meaningful access to care. The Affordable Care Act (ACA) created the first federal standard for network adequacy in the commercial insurance market for plans offered through the law’s insurance marketplaces. However, states continue to play a primary role in setting and enforcing network rules. This brief examines state network adequacy standards for marketplace plans in the 50 states and District of Columbia.

The Affordable Care Act (ACA) set new standards for the adequacy of health insurance, including limits on out-of-pocket cost-sharing and requirements that insurers cover a minimum set of health benefits. Yet while we know that access to health insurance has improved, our understanding of consumers’ experiences with plans’ cost-sharing, provider networks, and benefit design is lacking. One source of information about consumers’ coverage experiences are the state-run Consumer Assistance
Programs (CAPs) call centers, which receive calls from consumers on a wide range of issues, from those seeking coverage to those with coverage that is not meeting their needs. These programs provide a unique lens on consumer experiences with coverage both before and after the ACA went into full effect in 2014. They can help us understand how consumers have benefited from the insurance reforms, and where there may still be gaps or problems with their insurance coverage.
 

On February 27, 2015, the U.S. Department of Health and Human Services published the Notice of Benefit and Payment Parameters for 2016 Final Rule, which included several provisions pertaining to form review.  This analysis, prepared by the Georgetown University Health Policy Institute’s Center on Health Insurance Reforms, provides a brief summary of the key provisions specific to form review and other notable provisions specific to the 2016 plan year.  Included in the final rule are provisions on enrollment periods, definition of habilitative services, meaningful access to coverage materials, annual update to cost-sharing limits, pediatric age, and the drug exceptions process.

For the past three years, the Affordable Care Act (ACA) has required health insurers to pay out a minimum percentage of premiums in medical claims or quality improvement expenses—known as a medical loss ratio (MLR). Insurers with MLRs below the minimum must rebate the difference to consumers. This issue brief finds that total rebates for 2013 were $325 million, less than one-third the amount paid out in 2011, indicating much greater compliance with the MLR rule. In the first three years under this regulation, total consumer benefits related to the medical loss ratio—both rebates and reduced overhead—amounted to over $5 billion. This was achieved without a great exodus of insurers from the market.

For the past three years, the Affordable Care Act (ACA) has required health insurers to pay out a minimum percentage of premiums in medical claims or quality improvement expenses—known as a medical loss ratio (MLR). Insurers with MLRs below the minimum must rebate the difference to consumers. This issue brief finds that total rebates for 2013 were $325 million, less than one-third the amount paid out in 2011, indicating much greater compliance with the MLR rule. In the first three years under this regulation, total consumer benefits related to the medical loss ratio—both rebates and reduced overhead—amounted to over $5 billion. This was achieved without a great exodus of insurers from the market.

The failure of the health insurance cooperative operating in Iowa and Nebraska, together with the significant financial losses experienced by most others, have raised questions about the viability of the Affordable Care Act’s Consumer Operated and Oriented Plan (CO-OP) program. The program, which offers low-interest loans to co-ops, was designed to inject competition into highly concentrated markets and provide more affordable, consumer-focused alternatives to traditional insurance companies. This new blog post explains what’s behind the CO-OP program’s mixed performance so far and also points to reasons why success is still within reach.

The risk corridor program created by the Affordable Care Act (ACA) has proven to be one of the most controversial aspects of the health care law. Questions have been raised about the source of payments, whether the Department of Health and Human Services (HHS) has the authority to make payments under the program, and whether the program is required to be budget neutral. This brief has been updated to examine the impact of the Consolidated and Further Continuing Appropriations Act of 2015 on the risk corridor program and whether insurers will receive their full 2014 risk corridor payments.

In order to ensure that Consumer Services Divisions within state insurance regulatory agencies are equipped with the necessary resources to assist consumers experiencing insurance problems, the State Health Reform Assistance Network has developed a toolkit intended as a guide for consumer service representatives (CSRs). The resources in this updated toolkit include a reference manual with multiple entries across a number of categories, a glossary of acronyms, terms, and definitions, a benefits crosswalk template, and a reference table illustrating the applicability of ACA provisions to grandfathered and self-funded plans. 

The Affordable Care Act (ACA) requires health insurers to justify rate increases that are 10 percent or more for non-grandfathered plans in the individual and small-group markets. In analyzing these filings for renewals taking effect from mid-2013 through mid-2014, this brief finds that the average rate increase submitted for review was 13 percent. Insurers attributed the great bulk of these larger rate increases to routine factors, such as trends in medical costs. Most insurers did not attribute any portion of these medical cost trends to factors related to the ACA. The ACA-related factors mentioned most often were nonmedical: the new federal taxes on insurers, and the fee for the transitional reinsurance program.

The Affordable Care Act (ACA) protects people from being charged more for insurance based on factors like medical history or gender and establishes new limits on how insurers can adjust premiums for age, tobacco use, and geography. This brief examines how states have implemented these federal reforms in their individual health insurance markets. The authors identify state rating standards for the first year of full implementation of reform and explore critical considerations weighed by policymakers as they determined how to adopt the law’s requirements. Most states took the opportunity to customize at least some aspect of their rating standards.