Updated: Department of Insurance Consumer Services ACA Toolkit
Sally McCarty, David Cusano, Justin Giovannelli, and Max Farris, Georgetown University Health Policy Institute
In order to ensure that Consumer Services Divisions within state insurance regulatory agencies are equipped with the necessary resources to assist consumers experiencing insurance problems, the State Health Reform Assistance Network (State Network) team at the Georgetown University Health Policy Institute has developed a toolkit intended as a guide for consumer service representatives (CSRs). The passage of the Affordable Care Act requires CSRs to maintain a level of familiarity with a new set of marketplace rules, benefit requirements, and reforms that regulate health insurer behavior. Assuring that CSRs are familiar with these new requirements presents a significant challenge to busy insurance regulators who also have additional new responsibilities under the ACA.
The resources in this toolkit include a reference manual with multiple entries across a number of categories, a glossary of acronyms, terms, and definitions, a benefits crosswalk template, and a reference table illustrating the applicability of ACA provisions to grandfathered and self-funded plans. The toolkit is in word format and is designed to be a template which insurance regulators can use to create their own state-specific manual tailored to individual state laws, rules, and bulletins. This toolkit is designed to be used in real time when CSRs are interfacing with consumers.
As of June 24, 2015, this document has been revised to reflect the below changes.
Section I – Health Insurance Basics
The description of “Health Savings Accounts” has been revised to include the contribution amounts for 2015.
The definition of “excepted benefit plans” has been revised to reflect the requirements under the final rule.
Section III – Purchasing and Renewing a Policy
The definition of “rescission” has been revised to more accurately reflect the requirements under federal law.
Section IV – Enrollment Eligibility
The open enrollment periods and triggering events have been revised to reflect updates to federal law.
The prohibition on waiting periods description has been revised to reflect a permissible one-month orientation period.
Section V – Discrimination
An additional example of discrimination has been added in the 2nd paragraph of the “discrimination in benefit plan design prohibited” subsection.
Section VI – Policy Coverage Requirements
The out-of-pocket limits have been updated.
The section addressing separate out-of-pocket maximums for benefits administered by third party administrators has been deleted because it’s no longer applicable.
Section VII – Notice Requirement
First paragraph has been updated to note that the SBC must be provided within 90 days of special enrollment.
The “accessibility of applications and notices” subsection has been updated to note that oral interpretation includes telephonic interpreter services in 150 languages.
On November 15, 2023, the Centers for Medicare & Medicaid Services released its proposed 2025 Notice of Benefit and Payment Parameters, the annual regulation which governs core provisions of the Affordable Care Act. This expert perspective focuses on aspects of the proposed rule likely to be of interest to state officials, including requirements for State-Based Marketplaces to align with the standards of the Federally Facilitated Marketplace, proposals for states to update essential health benefits, and initiatives to ease the eligibility and enrollment process for consumers.
This expert perspective summarizes CMS’ new Informational Bulletin and accompanying framework which together detail Medicaid coverage options for services that address the health-related social needs (HRSN) of Medicaid enrollees. The new guidance reiterates the importance of addressing HRSNs to improve access to care and health outcomes, and summarizes (and in some cases updates) multiple previous sources of CMS guidance on how HRSN services may be covered in Medicaid, including guidance on in lieu of services authority and on HRSN coverage in section 1115 waivers.
