Insurance Market Reform

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.

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.

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.