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 January 15, 2025, the Centers for Medicare & Medicaid Services released updated State Health Official letter and Frequently Asked Questions guidance, replacing a previously issued SHO letter and FAQs on the requirement in the Consolidated Appropriations Act, 2023 that states provide 12 months of continuous eligibility for children and youth under the age of 19 in Medicaid and the Children’s Health Insurance Program, effective as of January 1, 2024.
Following the November release of guidance to support states’ efforts to verify eligibility and conduct renewals in compliance with federal Medicaid and CHIP requirements, the Centers for Medicare & Medicaid Services issued on December 20 two additional Center for Medicaid and CHIP Services Informational Bulletins (CIBs). This expert perspective summarizes the requirements outlined in the CIBs.
