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.
With the Patient Protection and Affordable Care Act’s (ACA’s) ninth open enrollment period (OEP) set to launch in less than a month, the ACA Marketplaces are seeing record enrollment numbers with more generous subsidies, new carrier competition, and a relatively stable rating environment. At the same time, there is uncertainty with the trajectory of the COVID-19 pandemic and medical costs trending upward as the economy recovers, albeit at an uneven pace. These trends have made for a challenging rate review process in the 47 states plus the District of Columbia (D.C.) that conduct their own ACA rate reviews of carrier-proposed rates using federal review standards. State announcements of 2022 rates have trickled out at a slower pace than in prior years, and it is likely that many states will not publish their approved rates until the beginning of open enrollment. As always, state rate results vary widely and, even within states, there often are substantial variations among carriers and across different regions in geographically diverse states. With these caveats, this expert perspective highlights some observations about the factors that are impacting rate changes this year and the kind of variations that exist among states.
As state-based marketplaces (SBMs) get ready for the next annual open enrollment period for health insurance, for many it represents a renewed opportunity to build on the hard work and lessons learned that took place over the year to enroll individuals in quality and affordable health coverage. The challenge for SBMs is getting all consumers to check out their options for the coming year and find the health coverage that best meets their needs now. In addition, for those new to the marketplace, SBMs will need to help these individuals navigate a process that may be unfamiliar. Many SBMs are making concerted efforts to connect residents with public and private health coverage options and are continuing to communicate the new financial help available through the American Rescue Plan. The ongoing COVID-19 pandemic continues to bring uncertainty for consumers and a need for marketplaces to continue to respond to that reality. This expert perspective highlights key messaging and outreach strategies state-based marketplaces are employing to conduct outreach, provide enrollment assistance, and clearly communicate with consumers what health coverage options are available for them in 2022.
