The scope of federal regulation affecting private health coverage has increased significantly since the passage of the Affordable Care Act (ACA) in 2010. The ACA introduced a range of new provisions and requirements for insurers, employer-sponsored plans, and providers, with the goal of expanding health coverage to more individuals and improving the overall quality of care. However, the law has also been the subject of ongoing debate and litigation, with efforts to repeal and replace it, as well as numerous court challenges.
Federal regulations have been categorized into six main areas: access to health coverage, affordability of health coverage, benefit design and adequacy, reporting and disclosure of information, review and appeal of health claims, and other federal standards. The ACA established core market rules to expand coverage, including requirements for premium stabilization and efforts to protect the risk pool. The law also introduced new standards for benefit design and adequacy, such as the requirement that all private, non-grandfathered health plans cover preventive services with no cost sharing for enrollees.
Access to coverage has been a key focus of federal regulation, with efforts to address barriers to coverage, such as preexisting condition exclusions and underwriting. The ACA prohibited insurers from declining to cover or renew coverage due to a person’s health status or claims history, and introduced new rules for premium stabilization and risk pool protection. The law also introduced new standards for financial protection and affordability, such as limits on out-of-pocket costs and requirements for transparency in plan design and operation.
Benefit design and adequacy have also been subject to federal regulation, with requirements for minimum standards for plan design and operation. The ACA introduced new rules for required coverage, including preventive services, and prohibited plans from imposing annual dollar limits on coverage or requiring waiting periods longer than 90 days before employer-sponsored coverage kicks in. States may have additional benefit mandates for state-regulated plans, such as comprehensive coverage requirements for mental health or substance use disorders.
Disclosure, reporting, and transparency requirements have also been introduced, with the goal of making more information available to enrollees and federal agencies. These requirements include disclosure of information to enrollees and the public, as well as reporting to federal agencies. The ACA introduced new rules for claims and appeals processes, including faster and fairer review processes, and established a federal floor of protections for the internal claims and appeals process.
Other federal standards, such as civil rights laws, antitrust laws, and privacy laws, also apply to private health insurance. The Civil Rights Act of 1964 and the Americans With Disabilities Act of 1990 created protections against discrimination based on race, color, national origin, sex, age, and disability. Antitrust laws prohibit anticompetitive practices and mergers by health care providers, hospitals, and insurers, while privacy laws, such as HIPAA, regulate the use of certain patient information. Special privacy protections for substance use disorder information are also regulated under a law known as “Part 2.” Plans and issuers are prohibited from entering into agreements that restrict access to claim, cost, or quality information, known as “gag clauses.”