Insurance Market Reform

Part of states' roles in administering the new health insurance marketplaces is to certify the health plans available for purchase. This analysis focuses on how state-based and state partnership marketplaces are using their flexibility in setting certification standards to shape plan design in the individual market. It focuses on three aspects of certification: provider networks; inclusion of essential community providers; and benefit substitution, which allows plans to offer benefits that differ from a state’s benchmark plan.

This notice with comment describes the overall Quality Rating System (QRS) framework for rating Qualified Health Plans (QHPs) offered through an Exchange. The purpose of this notice is to solicit comments on the list of proposed QRS quality measures that QHP issuers would be required to collect and report, the hierarchical structure of the measure sets and the elements of the QRS rating methodology. In addition, this notice solicits comments on ways to ensure the integrity of QRS ratings, and on priority areas for future QRS measure enhancement and development.

This proposed 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 proposes additional standards with respect to composite rating, 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, etc.

This final rule establishes the annual fee that will be imposed on health insurers, HMOS, self-insured Multiple Employment Welfare Arrangements (MEWAs), and entities that provide coverage under Medicare Parts C and D and Medicaid beginning in 2014. This health insurance tax is intended to help fund the insurance coverage expansion under the ACA.

This paper explores several strategies states could implement beyond federal requirements, using policy decisions in 11 states—Alabama, Colorado, Illinois, Maryland, Michigan, Minnesota, New Mexico, New York, Oregon, Rhode Island, and Virginia—to illustrate the choices being made to protect against and mitigate the effects of both “rate shock” and adverse selection in the individual market . The findings indicate that study states had mixed approaches to mitigating rate shock and adverse selection, with some taking steps beyond the required federal measures but with other policy options left unexplored. Minimizing the impact of adverse selection—both against the overall insurance market and the exchanges—will require strong monitoring and oversight.

This final rule maintains the protections of the Mental Health Parity Act of 1996 and adds new protections. The rule requires insurance companies to offer mental health and substance-use disorder benefits that are comparable to their medical and surgical benefits. However, the final rule does not require employers to offer mental health coverage.

This new Alliance for Health Reform Toolkit, produced with the support of the Robert Wood Johnson Foundation, details the ACA's employer requirements and penalty. It also provides information about the delay in the employer mandate to 2015, and analysis about its impact on employer-based coverage. The Toolkit includes: key facts about the employer mandate; data about trends in employment-based health coverage; links to news articles and reports explaining and analyzing the issue; and health care experts who understand the issue and its implications, along with contact info.

This most federal guidance clarifies that individuals have until March 31, 2013 to enroll in coverage through the health insurance marketplaces to avoid being subject to the penalty for not maintaining minimal essential coverage.

On August 30, 2013, the IRS published final regulations implementing the shared responsibility provisions of the ACA. The regulations address, among other matters, the complex question of when Medicaid eligibility amounts to minimum essential coverage (MEC) for purposes of the Act’s tax penalties. Because people with MEC are barred from receiving premium and cost sharing assistance for Marketplace plans, the final rules also have important implications in the area of health policy for children and adults with disabilities, who may need both basic insurance and supplemental Medicaid coverage for their more extensive health care needs. Many of Medicaid’s most important disability-related eligibility categories are optional with states and, therefore, monitoring whether and how agency policy on when Medicaid counts as MEC will be an important issue to watch over time.

The Multi-State Plan Program, established under the Affordable Care Act , directs OPM to contract with private health insurers in each State to offer high-quality, affordable health insurance options called Multi-State Plans (MSPs). MSPs are being administered in 30 states and the District of Columbia. This map details the MSP options that are available in the participating states.