Private Health Insurance Market Reforms in the Patient Protection and Affordable Care Act (ACA)

To contact us Click HERE


Annie L. Mach
Analyst in Health Care Financing

Bernadette Fernandez
Specialist in Health Care Financing

Theprivate health insurance provisions in the Patient Protection and AffordableCare Act (ACA, P.L. 111-148, as amended) include market reforms thatimpose requirements on private health insurance plans. Such reforms relateto the offer, issuance, generosity, and pricing of health plans, amongother requirements.

ACA’s market reforms largely focus on the individual and small group healthinsurance markets, and in this report the reforms have been grouped byeffective dates: “immediate” market reforms that become effective priorto the full implementation date of ACA, and reforms that become effectiveon the full implementation date (January 1, 2014).

ACA requires implementation of a number of reforms prior to its fullimplementation date (i.e., prior to plan years beginning on or afterJanuary 1, 2014). “Immediate” reforms include a process to reviewunreasonable rate increases; an Internet portal to assist consumers inidentifying coverage options; prohibition on lifetime limits andrestriction of annual limits; the prohibition on rescissions; coverage ofpreventive health services with no cost-sharing; extension of dependent coverage;prohibition of discrimination based on salary; standards related to medicalloss ratios and rebates to plan participants; appeals processes; coverageof preexisting health conditions for children; patient protections;uniform explanation of coverage documents; and reporting requirementsregarding quality of care.

Market reforms effective beginning in 2014 include nondiscrimination based onhealth status; guaranteed issue and guaranteed renewability; coverage ofpreexisting health conditions (regardless of age); nondiscriminationregarding clinical trial participation; rating restrictions; waitingperiod limitation; and nondiscrimination regarding health care providers.

This report provides background information about the private health insurancemarket, including market segments and regulation. It describes each ACAmarket reform and notes any major implementation activity that hasoccurred (e.g., issuance of final rule from a department such as Healthand Human Services). The appendices of the report provide additionalinformation about the status of regulations relating to each reform (AppendixA) and how the reforms apply to the different market segments andhealth plans (Appendix B).


Date of Report: February 5, 2013
Number of Pages: 27
Order Number: R42069
Price: $29.95

To Order:


R42069.pdf to use the SECURE SHOPPING CART

e-mail congress@pennyhill.com

Phone301-253-0881

For email and phone orders, provide a Visa, MasterCard, American Express, or Discover cardnumber, expiration date, and name on the card. Indicate whether you want e-mailor postal delivery. Phone orders are preferred and receive priority processing.