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Health Care Reform News

Final Rule Issued on Standards Insurance Market Reforms and Rate Rules

February 26, 2013



The Department of Health and Human Services (HHS) has released the Final Rule on Insurance Market Reforms and Rate Review. The rule finalizes new individual and small group insurance reform rules that apply both inside and outside of the exchange. The final rule largely tracks the proposed rule released last year. Key changes from the Proposed Rule include:

  • Participation/Contribution Requirements - The Final Rule has eliminated the use of participation and contribution requirements in issuing coverage to small employers during an annual open enrollment period from November 15 to December 15 each year.
  • Rating - The Final Rule maintains the "3 to 1" age rating band and makes several changes to other rating factors:
    • Family Rating - The Final Rule allows states to define who is eligible for coverage on a family policy.
    • Geography - The Final Rule removes the requirement for states to establish no more than seven rating areas within the state. In addition, the Final Rule includes a "default" if states fail to specify rating areas. The default establishes rating areas for each Metropolitan Statistical Area (MSA). A MSA is determined by an urban area with a minimum population of 50,000 people plus adjacent territories with a high degree of social and economic integration. The Rule also states that the default must include one area for all of the states non-MSA areas. 
    • Tobacco - The Final Rule allows issuers to retroactively adjust premiums for persons who misrepresent their use of tobacco.  The issuer is however, prohibited from rescinding coverage as HHS doesn't view this as a material misrepresentation.

To learn more about the Final Rule, see the attached document. Additional information on health care reform can be found on


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