Insurance Market Reform

This proposed rule provides payment parameters and provisions related to the risk adjustment, reinsurance, and risk corridors programs; cost sharing parameters and cost-sharing reductions; and user fees for Federally-facilitated Exchanges. It also provides additional standards for the annual open enrollment period for the individual market for benefit years beginning on or after January 1, 2016, essential health benefits, qualified health plans, network adequacy, quality improvement strategies, the Small Business Health Options Program, guaranteed availability, guaranteed renewability, minimum essential coverage, the rate review program, the medical loss ratio program, and other related topics. Comments on the proposed rule are due by December 22, 2014.

This guide is focused solely on the private insurance reforms of the ACA, including the health insurance marketplaces, rating, benefit and cost structures, and premium tax credits. It is intended to supplement the Navigator training available from the U.S. Department of Health and Human Services. It is not intended to be a comprehensive, stand-alone resource for all the reforms of the ACA. This resource is organized into sections that address how individuals may present themselves to Navigators based on their insurance status and coverage options. It includes questions and answers developed in collaboration with the staff at the Center on Budget and Policy Priorities, the Georgetown University Center for Children and Families, and the Kaiser Family Foundation.
 

One objective of the health insurance Marketplaces created through the Affordable Care Act (ACA) is to encourage competition among insurers with the goal of lower premiums for consumers and lower subsidy costs for the federal government. One strategy insurers have used to offer lower premiums and capture market share has been the creation of “narrow networks” of providers and facilities. The ACA includes network adequacy requirements, but there remains considerable variation in the breadth of acceptable hospital networks and the options available in each. This brief investigates which hospitals are included in Marketplace plans in major cities in six states, and examines how hospital networks vary across plans within a single insurer and across all insurers.
 

During the transition to new health plans and new marketplaces under the ACA, many insurers revamped their approach to network design, and many now offer narrower provider networks than they have in the past. In this study for the Robert Wood Johnson Foundation’s project to monitor ACA implementation, researchers assessed network changes and efforts at regulatory oversight in six states: Colorado, Maryland, New York, Oregon, Rhode Island, and Virginia. Researchers found that insurers made significant changes to the provider networks of their individual market plans, both inside and outside the marketplaces, and that insurers took varying approaches to network design.
 

The Affordable Care Act (ACA) includes certain requirements regarding the adequacy of provider networks developed by health insurers to deliver covered services to their enrollees. The requirements provide broad parameters within which insurance regulators and other state officials responsible for network adequacy must evaluate the networks of Qualified Health Plans operating in their markets. This network adequacy planning tool for states has been updated to reflect the most recent U.S. Department of Health and Human Services regulation on minimum network adequacy standards, and can assist states in developing analysis plans that will inform discussions around updating network adequacy standards.
 

In order to encourage entry and lower prices, most regulated markets for health insurance include policies that seek to reduce the uncertainty faced by insurers. In addition to risk adjustment of premiums paid to plans, the Health Insurance Marketplaces established by the Affordable Care Act implement reinsurance and risk corridors. Reinsurance limits insurer costs associated with specific individuals, while risk corridors protect against aggregate losses. Both tighten the insurer’s distribution of expected costs. This paper considers the economic costs and consequences of reinsurance and risk corridors.
 

In the first year of full implementation, enrollment in the Affordable Care Act’s (ACA) health insurance exchanges largely fulfilled expectations, following a rocky beginning. Now, attention is turning to 2015, and one of the first tangible tests of how well the ACA is working will be the changes in premiums in the new health insurance marketplaces. This brief presents an initial analysis of premium changes for marketplace plans for individuals in 15 states plus the District of Columbia, where comprehensive data was available on rates or rate filings for all insurers.
 

To better understand the nature of coverage available to consumers through the Exchanges, Breakaway Policy Strategies partnered with the Robert Wood Johnson Foundation to collect detailed information on premiums, network composition, deductibles, out-of-pocket limits, and cost-sharing for every 2014 Silver Exchange plan in all 50 states and the District of Columbia. This report takes a closer look at cost-sharing for primary care physician (PCP) and specialist visits, including application of plan deductibles, copayment and coinsurance amounts, and the unique plan design features that may lead some enrollees to think twice before scheduling their next appointment with a doctor.
 

As rate filings for 2015 Affordable Care Act (ACA) health plans become public, virtually all media attention has focused on premium changes. What have been ignored are the changes in the plans’ out-of-pocket expenses. Inasmuch as deductibles and physician fees have the potential to add thousands of dollars in annual healthcare expenses, media disregard of health plan cost-sharing is especially unhelpful to the portion of the public who uses healthcare services regularly. This report examines major out-of-pocket cost categories within public rate filings for 2015 Affordable Care Act plans in 9 states.
 

The Affordable Care Act (ACA) contains numerous consumer protections designed to remedy shortcomings in the availability, affordability, adequacy, and transparency of individual market insurance. However, because states remain the primary regulators of health insurance and have considerable flexibility over implementation of the law, consumers are likely to experience some of the new protections differently, depending on where they live. This brief explores how federal reforms are shaping standards for individual insurance and examines specific areas in which states have flexibility when implementing the new protections