Highlights of Proposed Rules on Health Insurance Market Rules

Source: United Benefit Advisors

On Nov. 20, 2012, the Department of Health and Human Services (HHS) issued proposed rules that address a number of health insurance market reforms. The rule is still in the “proposed” stage, which means that there may — and likely will — be changes when the final rule is issued. The proposed rule confirms that non-grandfathered health insurers (whether operating through or outside an exchange) would be prohibited from denying coverage to someone because of a pre-existing condition or other health factor. Individuals generally would be required to purchase coverage during an open enrollment period, with special enrollment periods available following qualifying events. Small employers would be able to purchase coverage throughout the year.

The proposed rule reiterates PPACA’s limits on permissible premium variations for policies in the exchanges and individual and small group markets, providing that premiums may only vary based upon:

  • Age (with a maximum 3-to-1 ratio, which is well below the 5-to-1 or 6-to-1 ratio currently in use in some states)
  • Tobacco use (with a maximum 1 and ½-to-1 ratio)
  • Geographic location
  • Family size




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