Guaranteed Availability of Coverage

Health insurance issuers are to offer coverage to and accept every employer or individual who applies for coverage in the group and individual market, subject to certain exceptions.

Guaranteed Availability of Coverage (applies to non-grandfathered plans)

Exceptions allow issuers to restrict enrollment in coverage to: 1) open and special enrollment periods, 2) employers with eligible individuals who live, work, or reside in the service area of a network plan, and 3) for situations involving limited network capacity and limited financial capacity. The final rule specifies that:

  • Small and large employers cannot be denied coverage for the failure to satisfy minimum participation or contribution requirements.
    However, while the standard for the small group market is continuous open enrollment, issuers may limit their offering of coverage to an annual open enrollment period (November 15 – December 15) for those employers in the small group market which fail to meet the issuer’s standard minimum participation and contribution requirements.
  • The final rule maintains the requirement that there would be “limited” open enrollment periods in the individual market consistent with Exchange rules (aligning initial and annual open enrollment periods outside the Exchanges with those inside the Exchanges). In addition, an individual enrolled in a non-calendar year plan will be entitled to a limited open enrollment period beginning 30 calendar days prior to the individual’s policy renewal date outside the open enrollment period for 2014. States may permit more flexible open enrollment provisions.
  • Enrollment periods specific to special circumstances (e.g., loss of other coverage, birth, marriage, etc.) will be 60 days in the individual market (consistent with Exchange rules) and 30 days in the group market.
    Discriminatory marketing practices or benefit designs that discourage enrollment based on health needs in coverage, such as discrimination based on age, disability, race, ethnicity, gender, and sexual orientation are prohibited.
    Future guidance will address strategies to limit adverse selection related to guaranteed availability.
    Guaranteed Renewability of Coverage (applies to non-grandfathered plans)
  • Health insurance issuers must renew or continue in force coverage in the group and individual market at the option of the plan sponsor or the individual with limited exceptions. Exceptions to this requirement include the failure to meet minimum participation or contribution standards in the small group market.
  • Rate Review Program

    The final rule largely implements changes to rate review requirements contained in the proposed rule, including the requirement that all rate increases be filed with HHS, not just those of 10 percent or greater. However, the final rule added the requirement that if any product is subject to a rate increase, the issuer must submit a Rate Filing Justification for all products in the single risk pool, including new or discontinuing products.

    Catastrophic Plans

    The final rule establishes standards for enrollment in catastrophic plans for young adults and people who cannot otherwise afford health insurance. The catastrophic plan will have a lower premium, protect against high out-of-pocket costs and cover recommended preventive services without cost sharing. The provisions for catastrophic plans apply to coverage offered both inside and outside of an Exchange. To be eligible to enroll in a catastrophic plan, individuals must meet special eligibility criteria provided by the ACA.

    Special Plan Types

    The final rule exempts all student health insurance coverage from the single risk pool requirements (including guaranteed availability and renewability requirements). Sub-regulatory guidance issued at the time also clarifies that student health insurance coverage is not subject to federal rate review requirements at this time. Additionally, future guidance will be issued on the applicability of the market reform provisions to expatriate plans.

    Leave a Reply

    Your email address will not be published. Required fields are marked *