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Health Care Reform News

Health Insurance Market Rules and Rate Review rules intended to protect consumers

November 26, 2012


The Department of Health and Human Services (HHS) has published a series of proposed rules implementing several Affordable Care Act (ACA) insurance reforms, including Health Insurance Market Rules and Rate Review, which prevents insurance companies from denying coverage to individuals with pre-existing health conditions, and protects against excessive premium increases.


The proposed rules, which apply to plan years beginning on or after January 1, 2014, include these provisions:

  • Guaranteed Issue.  Health insurance issuers are prohibited from denying coverage to people due to a pre-existing condition or any other factor. Individuals generally would need to buy coverage during open enrollment periods. In addition, individuals would have new special enrollment opportunities in the individual market when they experience certain losses of other coverage.
  • Single Risk Pool. Health insurance issuers would be required to maintain a single statewide risk pool for each individual and small group market, unless a state chooses to merge the individual and small group pools into one pool. Premiums and annual rate changes would be based on the health risk of the entire pool. 
  • Guaranteed Renewal.  The proposed rule reaffirms existing protections that individuals and employers have with respect to coverage renewal. For example, these protections would prohibit issuers from refusing to renew coverage because an individual or employee becomes sick or has a pre-existing condition.
  • Rating.  Standardizes rating methodologies (particularly with respect to age rating and certain aspects of family rating), but permits issuer or state flexibility. Other factors - such as pre-existing conditions, health status, claims history, duration of coverage, gender, occupation, and small employer size and industry - would no longer be used by insurance companies to increase the premiums for those seeking insurance. 
  • Catastrophic Plans. The proposed rule includes provisions for enrollment in catastrophic plans, with lower premiums, protection against high out-of-pocket costs, and coverage of recommended preventive services without cost sharing.


For a complete review of the proposed ruling, please see the attached document. Additional information on health care reform can be found on

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