Market Rules Under the Affordable Care Act
Under the Affordable Care Act (ACA), Market Rules ensure that individuals and employers will have a minimum set of protections for health insurance access and premium stability in all states, inside and outside of the Health Insurance Marketplace.
This is a summary of the ACA Market Rules as they relate to Guaranteed Availability, Guaranteed Renewability, Single Risk Pool and Rating Standards provisions.
The provisions within the chart below are effective for plan years beginning on or after January 1, 2014.
EHB categories
Provision
|
Impact
|
Summary
|
---|---|---|
Guaranteed Availability
Guaranteed Renewability |
Non-grandfathered individual and group insured plans
|
Guaranteed Availability – Insurers must accept every individual and group that submits an application for coverage, regardless of medical history or health status.
Guaranteed Renewability – Insurers must renew coverage for every individual or group that wants to renew. |
Single Risk Pool
|
Non-grandfathered individual and small group insured plans
|
Insurers cannot use separate risk pools to charge certain policyholders higher rates.
|
Rating Standards (Fair Health Insurance Premiums)
|
Non-grandfathered individual and small group insured plans; may be extended to large group plans in 2017
|
Health insurance policy premiums can vary based only on these four factors:
|
Guaranteed availability/guaranteed renewability
Guaranteed availability
|
Guaranteed renewability
|
---|---|
Coverage must be offered to all applicants, with few exceptions
|
Coverage must be renewed for all policyholders, with few exceptions
|
|
|
Single risk pool
- Insurers cannot use separate risk pools to charge certain customers higher rates. Insurers must use the total combined claims experience of all their non-grandfathered individual or small group plans in a state to establish an index rate (average rate) for that market.
- This index rate will be used to set rates for all of the insurer’s products in that market.
Rating standards
This chart provides more details about each of the four rating factors.
Rating factors
|
Details
|
---|---|
Age
|
|
Tobacco use
|
A plan will not be allowed to charge a tobacco user more than 1.5 times the rate charged to an individual who does not use tobacco.
|
Family size
|
To determine a rate for family coverage, insurers must calculate rates on a per-family-member basis. The specific rates for each family member are combined to determine a total rate for the insured family.
|
Geography/rating area
|
Different geographic regions have different costs for health care, and insurers may determine health insurance premiums accordingly.
|
Effective July 16, 2014, the guaranteed availability, guaranteed renewability and single risk pool provisions no longer apply to insured plans issued in the U.S. territories (Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa and the Northern Mariana Islands).
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Individual and family medical and dental insurance plans are insured by Cigna Health and Life Insurance Company (CHLIC), Cigna HealthCare of Arizona, Inc., Cigna HealthCare of Illinois, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of South Carolina, Inc., and Cigna HealthCare of Texas, Inc. Group health insurance and health benefit plans are insured or administered by CHLIC, Connecticut General Life Insurance Company (CGLIC), or their affiliates (see
All insurance policies and group benefit plans contain exclusions and limitations. For availability, costs and complete details of coverage, contact a licensed agent or Cigna sales representative. This website is not intended for residents of New Mexico.