Insurance Market Reform

This final rule sets forth payment parameters and oversight 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 with respect to composite premiums, privacy and security of personally identifiable information, the annual open enrollment period for 2015, the actuarial value calculator, the annual limitation in cost sharing for stand-alone dental plans, the meaningful difference standard for qualified health plans offered through a Federally-facilitated Exchange, patient safety standards for issuers of qualified health plans, and the Small Business Health Options Program.

This proposed rule would address various requirements applicable to health insurance issuers, Health Insurance Marketplaces, Navigators, non-Navigator assistance personnel, and other entities under the ACA. Specifically, the rule proposes standards related to product discontinuation and renewal, quality reporting, non-discrimination standards, minimum certification standards and responsibilities of qualified health plan (QHP) issuers, the Small Business Health Options Program, and enforcement remedies in Federally-facilitated Marketplaces.

This guide focuses on the private insurance reforms of the Affordable Care Act, including the health insurance marketplaces, rating, benefit and cost standards, and premium tax credits. It is intended to supplement the Navigator training available from the U.S. Department of Health and Human Services. This comprehensive resource addresses more than 230 enrollment questions about private insurance reforms, and is divided into four sections: individuals with no coverage; individuals who currently have coverage or an offer of coverage from their employer; coverage for small business employers; and post-enrollment issues.

States, whether or not they have decided to operate their own health insurance marketplaces, must navigate rapidly changing health insurance markets in which the ACA’s reforms are affecting insurers, businesses, and consumers. Under the ACA, states are primarily responsible for implementing significant insurance reforms that went into effect on January 1, 2014. This paper explores the responses of eight states to the ACA’s new rules and the creation of the new health insurance marketplaces.

This document contains final regulations providing guidance to employers that are subject to the shared responsibility provisions regarding employee health coverage enacted by the Affordable Care Act. These regulations affect large employers, those with 50 or more full-time employees, including full-time equivalent employees, during the prior year. Generally, an applicable large employer that, for a calendar month, fails to offer health coverage that is affordable and provides minimum value to its full-time employees may be subject to an assessable payment if a full-time employee enrolls for that month in a qualified health plan for which the employee receives a premium tax credit. These employers will need to begin complying with these regulations in 2015.