RESUMEN

Health plans with relatively narrow provider networks have generated widespread debate, mainly concerning the level of regulatory oversight necessary to ensure plans provide consumers meaningful access to care. The Affordable Care Act creates the first federal standard for network adequacy in the commercial insurance market for plans offered through the law's insurance marketplaces. However, states continue to play a primary role in setting and enforcing network rules. This brief examines state network adequacy standards for marketplace plans in the 50 states and District of Columbia. We identify state requirements in effect at the outset of marketplace coverage, focusing on quantitative measures of network sufficiency and rules designed to ensure the delivery of accurate and timely provider directories. We then explore the extent to which those standards evolved for 2015. Though regulatory changes were limited in year one, states were most likely to act to promote network transparency and enhance oversight.

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RESUMEN

The Affordable Care Act contains numerous consumer protections designed to remedy shortcomings in the availability, affordability, adequacy, and transparency of individual market insurance. However, because states remain the primary regulators of health insurance and have considerable flexibility over implementation of the law, consumers are likely to experience some of the new protections differently, depending on where they live. This brief explores how federal reforms are shaping standards for individual insurance and exam­ines specific areas in which states have flexibility when implementing the new protections. We find that consumers nationwide will enjoy improved protections in each area targeted by the reforms. Further, some states already have embraced the opportunity to customize their markets by implementing consumer protec­tions that exceed minimum federal requirements. States likely will continue to adjust their market rules as policymakers gain a greater understanding of how reform is working for consumers.

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The Affordable Care Act protects people from being charged more for insurance based on factors like medical history or gender and establishes new limits on how insurers can adjust premiums for age, tobacco use, and geography. This brief examines how states have implemented these federal reforms in their individual health insurance markets. We identify state rating standards for the first year of full implementation of reform and explore critical considerations weighed by policymakers as they determined how to adopt the law's requirements. Most states took the opportunity to customize at least some aspect of their rating standards. Interviews with state regulators reveal that many states pursued implementation strategies intended primarily to minimize market disruption and premium shock and therefore established standards as consistent as possible with existing rules or market practice. Meanwhile, some states used the transition period to strengthen consumer protections, particularly with respect to tobacco rating.

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The Affordable Care Act broadens and strengthens the health insurance benefits available to consumers by requiring insurers to provide coverage of a minimum set of medical services known as "essential health benefits." Federal officials implemented this reform using transitional policies that left many important decisions to the states, while pledging to reassess that approach in time for the 2016 coverage year. This issue brief examines how states have exercised their options under the initial federal essential health benefits framework. We find significant variation in how states have developed their essential health benefits packages, including their approaches to benefit substitution and coverage of habilitative services. Federal regulators should use insurance company data describing enrollees' experiences with their coverage--information called for under the law's delayed transparency requirements--to determine whether states' differing strategies are producing the coverage improvements promised by reform.

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The Affordable Care Act seeks to help small employers offer coverage by reforming the small-group market and establishing Small Business Health Options Program (SHOP) marketplaces. Seventeen states and the District of Columbia chose to operate their own SHOP marketplaces in 2014, with the federal government operating the SHOP marketplace in 33 states. This brief examines state decisions to enhance the value of SHOP marketplaces for small employers and finds that most have set predictable participation and eligibility requirements and will offer a competitive choice of insurers and plans. States also are seeking to facilitate small employers' shopping experience through online tools and access to personalized assistance. While not all SHOP marketplaces are yet functioning as intended, their establishment offers an opportunity to identify successful strategies for improving the affordability and accessibility of coverage for small employers.

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To improve the adequacy of private health insurance, the Affordable Care Act requires insurers to cover a minimum set of medical benefits, known as "essential health benefits." In implementing this requirement, states were asked to select a "benchmark plan" to serve as a reference point. This issue brief examines state action to select an essential health benefits benchmark plan and finds that 24 states and the District of Columbia selected a plan. All but five states will have a small-group plan as their benchmark. Each state, whether or not it made a benchmark selection, will have a set of essential health benefits that reflects local, employer-based health insurance coverage currently sold in the state. States adopted a variety of approaches to selecting a benchmark, including intergov­ernmental collaboration, stakeholder engagement, and research on benchmark options.

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The Affordable Care Act includes numerous consumer protections designed to improve the accessibility, adequacy, and affordability of private health insurance. Because states are the primary regulators of health insurance, this issue brief examines new state action on a subset of protections--such as guaranteed access to coverage and a ban on pre­existing condition exclusions--that go into effect in 2014. The analysis finds that, to date, only one state passed new legislation on all of these protections, and an additional 10 states and the District of Columbia passed new legislation or issued a new regulation on at least one protection. The analysis also finds that--without new legislation--some states face limitations in fully enforcing these reforms. These findings suggest an acute need for states to take action in 2013 to help ensure that consumers are fully protected by and benefit from the Affordable Care Act's most significant reforms.

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The new health insurance marketplaces aim to improve consumers' purchasing experiences by setting uniform coverage levels for health plans and giving them tools to explore their options. Marketplace administrators may choose to limit the number and type of plans offered to further simplify consumer decision-making. This issue brief examines the policies set by some state-based marketplaces to simplify plan choices: adopting a meaningful difference standard, limiting the number of plans or benefit designs insurers may offer, or requiring standardized benefit designs. Eleven states and the District of Columbia took one or more of these actions for 2014, though their policies vary in terms of their prescriptiveness. Tracking the effects of these different approaches will enhance understanding of how best to enable consumers to make optimal health insurance purchasing decisions and set the stage for future refinements.

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The Affordable Care Act prohibited insurers from denying or limiting cover­age for children under the age of 19 in 2010. In response, some insurers ceased to offer coverage to children in need of individual health insurance, known as a "child-only" pol­icy. This issue brief examines new state legislative and regulatory action to promote the availability of child-only policies in response to this market disruption. The analysis finds that 22 states and the District of Columbia passed new legislation or issued a new regula­tion or subregulatory guidance. As a result, child-only coverage is available in nearly all of these states. These findings suggest that states have flexibility to take innovative actions to maintain or improve their markets and insurers are highly sensitive to the risk of adverse selection. The findings also suggest the need for meaningful regulatory incentives to avoid market disruption in successfully implementing broader reforms in 2014.

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The Affordable Care Act includes numerous consumer protections that took effect on September 23, 2010. This issue brief examines new state action on a subset of these "early market reforms." The analysis finds that 49 states and the District of Columbia have passed new legislation, issued a new regulation, issued new subregulatory guidance, or are actively reviewing insurer policy forms for compliance with these protections. These findings suggest that states have required or encouraged compliance with the early market reforms, and that efforts to understand how states are responding cannot focus on legislative action alone. The findings also raise important questions regarding how states may implement the Affordable Care Act's broader 2014 market reforms, and suggest the need for continued tracking of state action.

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