Insurance Market Reform

In March of 2012, the U.S. Department of Health and Human Services issued a regulation defining student health plans as individual health insurance under federal law. As a result, they are now subject to the same consumer protections afforded to all those covered by individual health insurance set forth in the Public Health Service Act, as amended by the Affordable Care Act (ACA). This issue brief examines student health plans, which cover over 1 million students, and investigates the interplay between federal and state regulation with regard to these plans.

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.

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.

The individual insurance market has changed substantially under the ACA. Starting in 2014, the health law put in place new rules for what types of plans can be sold, required insurance companies to guarantee access to everyone regardless of health status, and limited the factors insurers could use in setting premiums. As of the end of open enrollment in 2014, 8 million people had signed up for coverage through the Marketplaces. However, it has been unclear precisely how many of these Marketplace enrollees were previously uninsured or how many would have purchased individual coverage directly from an insurer in the absence of the ACA. This analysis of recently-submitted 2014 filings by insurers to state insurance departments shows that 15.5 million people had major medical coverage in the individual insurance market – both inside and outside of the Marketplaces – as of December 31, 2014. Enrollment was up 4.8 million over the end of 2013, a 46 percent increase.

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.