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The ACA’s Preventive Services Benefit Is in Jeopardy: What Can States Do to Preserve Access?

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…for the Commonwealth Fund’s To the Point blog, Georgetown researchers identify current state-level preventive service coverage requirements. At least 15 states have broad, ACA-style laws requiring individual market insurers to cover, without cost sharing, the same categories of preventive services required by the ACA. Several states have extended these protections to workers in the fully insured group market. However, state…

ERISA 101: The United States’ Hands-Off Approach to Regulating Employer Health Plans

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…Congress prohibited health plans from entering into agreements with service providers that contain gag clauses restricting the plan’s access to cost and quality information, including deidentified claims data. This effectively gives health plans a right to data that their vendors have long denied them. Congress also required brokers and other plan consultants to disclose all direct and indirect compensation they…

Navigator Guide FAQs of the Week: Post-enrollment Issues

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…such bills, including emergency care or an out-of-network provider at an in-network facility. If you went out-of-network because you felt it was medically necessary to receive care from a specific professional or facility—for example, if you felt your plan’s network didn’t include providers able to provide the care you need—you can appeal the insurer’s decision. If you inadvertently got out-of-network…

Can Employer-sponsored Insurance Be Saved? A Review of Policy Options: Price Regulation

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…hospital care makes up the largest single component of personal health care spending, an estimated 39 percent of the total in 2023, compared to 24 percent for physician and clinical services and 10 percent for prescription drugs. National spending on hospital care is projected to exceed $1.5 trillion in 2023, and is expected to grow by about 5.6 percent per…

December Research Roundup: What We’re Reading

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…including insufficient data, a lack of staff or software to evaluate network adequacy data, and challenges incorporating telehealth into network adequacy reviews. The Centers for Medicare & Medicaid Services (CMS) found that, as of August 2022. 243 out of 375 health plan issuers did not comply with network adequacy standards for Plan Year 2023 (though regulators indicated some compliance issues…

Navigator Guide FAQs of the Week: The End of Open Enrollment

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…help consumers through the process of finalizing their enrollment. I’ve picked the plan I want. Now do I send my premium to the marketplace? No, you will make your premium payments directly to the health insurance company. Once you’ve selected your plan, the marketplace will direct you to your insurance company’s website to make the initial premium payment. Insurance companies…

New CHIR Case Study Examines Policies to Expand Primary Care Access in Rural Arkansas

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By Maanasa Kona, Megan Houston, Jalisa Clark, and Emma Walsh-Alker Primary care is a critical tool to prevent illness and death and improve equitable distribution of health care. However, many people lack primary care access, especially underserved groups such as communities of color and people living in rural areas. In a new case study, published in collaboration with the Milbank…

Navigator Guide FAQs of the Week: Comparing Plans

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…reductions, you must enroll in a silver plan to obtain cost-sharing reductions that lower your out-of-pocket costs. (45 C.F.R. § 156.130; 45 C.F.R. § 147.130; 45 C.F.R. § 156.140). I am interested in making sure my plan includes a provider who is culturally competent. Do provider networks list the race/ethnicity of the provider or their experience with certain communities? Provider…

The Proposed 2024 Notice of Benefit & Payment Parameters: Implications for States

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By Sabrina Corlette and Tara Straw* On December 12, 2022, the Centers for Medicare & Medicaid Services (CMS) released its proposed Notice of Benefit & Payment Parameters for plan year 2024. This annual regulation governs core provisions of the Affordable Care Act (ACA), including operation of the health insurance marketplaces, standards for insurers, and the risk adjustment program. In a…

Navigator Guide FAQs of the Week: What to Know About Off-marketplace Plans

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…required to comply with important ACA consumer protections, such as coverage of pre-existing conditions. This week, as a part of CHIR’s weekly Navigator Resource Guide series, we’ve highlighted FAQs discussing some of the pitfalls of buying a plan off-marketplace. If I buy an individual health plan outside the health insurance marketplace, is my coverage going to be the same as…

The opinions expressed here are solely those of the individual blog post authors and do not represent the views of Georgetown University, the Center on Health Insurance Reforms, any organization that the author is affiliated with, or the opinions of any other author who publishes on this blog.