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Coverage and Market Reforms

Coverage Updates

States have the ability to decide the following regarding implementation:

  • Benefits offered by all plans in individual and small group markets.
  • Tighter restrictions on insurance companies in some areas.
  • Establishing a state-run Marketplace
  • Expansion of Medicaid (since the Supreme Court ruling in June 2012).
  • As a result of these variations, healthcare coverage continues to look different in each state.  

Market Reforms

As of January 1, 2014, new premium rating rules went into effect for plans in the individual and group markets. These federal changes only allow insurers to adjust premiums based on the following factors:

  • Individual versus family enrollment (number of family members in the plan)
  • State geography
  • Age: insurers can’t charge older adults more than three times what they charge younger adults
  • Tobacco use: insurers may charge tobacco users up to 1.5 times what they charge non-users

Adjusting premiums based on a person’s health status is prohibited.