Federal Requirements on Private Health Insurance Plans

Federal Requirements on Private Health
March 9, 2023
Insurance Plans
Ryan J. Rosso,
Insurance Plans Updated March 12, 2025 (R45146) Jump to Main Text of Report

Contents

• Introduction
• Background
• Types of Private Health Insurance Plans
• Certain Plan Variations
• Regulation of Private Health Plans
• Federal Requirements
• Obtaining Coverage
• Guaranteed Issue
• Employer Shared Responsibility Provisions
• Prohibition on Using Health Status for Eligibility Determinations
• Nondiscrimination Based on Genetic Information
• Extension of Dependent Coverage
• Prohibition of Discrimination Based on Salary
• Waiting Period Limitation
• Keeping Coverage
• Guaranteed Renewability
• Prohibition on Rescissions
• COBRA Continuation Coverage
• Coverage for Students Who Take a Medically Necessary Leave of Absence
• Health Insurance Premiums
• Prohibition on Using Health Status as a Rating Factor
• Rating Restrictions
• Rate Review
• Single Risk Pool
• Medical Loss Ratio
• Covered Benefits
• Coverage of Essential Health Benefits
• Coverage of Preventive Health Services Without Cost Sharing
• Coverage of COVID-19 Vaccinations and Other Qualifying Preventive Services
• Coverage for Individuals Participating in Approved Clinical Trials
• Coverage of Minimum Hospital Stay After Childbirth
• Mental Health Parity
• Coverage of Reconstruction After Mastectomy
• Coverage of Pregnancy-Related Conditions
• Prohibition on Coverage Exclusions Based on Preexisting Health Conditions
• Enrollee Cost Sharing and Plan Payment for Benefits
• Maximum Annual Limitation on Cost Sharing
• Minimum Actuarial Value Requirements
• Prohibition on Lifetime and Annual Coverage Limits
• Health Care Provider Interactions
• Preventing Surprise Medical and Air Ambulance Bills
• Continuity of Care
• Services Provided Based on Incorrect Provider Directory Information
• Choice of Health Care Professionals
• Nondiscrimination Regarding Health Care Providers
• Prohibition on Gag Clauses on Price and Quality Information
• Enrollee Information and Appeals
• Summary of Benefits and Coverage and Uniform Glossary
• Advanced Explanation of Benefits
• Plan Identification Card Information
• Price Comparison Tool
• Provider Directory Requirements
• Disclosure of Patient Protections Against Balance Billing
• Information on Prescription Drugs
• Disclosure to Enrollees of Individual Market Coverage
• Appeals Process and External Review
• Federal and Public Reporting Requirements
• Reporting Requirements Regarding Quality of Care
• Reporting Requirements Regarding Air Ambulances
• Reporting Requirements Regarding Pharmacy Benefits and Drug Costs
• Transparency in Coverage

Tables

• Table 1. Applicability of Selected Federal Requirements to Private Health Insurance Plans

Summary

A majority of Americans have private health insurance. Broadly, private health insurance A majority of Americans have private health insurance. Broadly, private health insurance
Coordinator
includes includes group plans (largely made up of (largely made up of employer-sponsored insurance) and ) and non-group plans
Analyst in Health Care
nongroup plans (i.e., plans a consumer purchases directly from an insurer). Group plans may be (i.e., plans a consumer purchases directly from an insurer). Group plans may be fully insured or or
Financing
self-insured, and fully insured plans may be purchased in the , and fully insured plans may be purchased in the large-group or or small-group

markets. (These terms are discussed in the report.)(These terms are discussed in the report.)
Vanessa C. Forsberg
Analyst in Health Care
Private health insurance plans must comply with requirements at both the state and federal levels, Private health insurance plans must comply with requirements at both the state and federal levels,
Financing
where applicable. Federal requirements for health plans are codified primarily in three statutes: where applicable. Federal requirements for health plans are codified primarily in three statutes:

Title XXVII of the Public Health Service Act (PHSA), Part 7 of the Employee Retirement Title XXVII of the Public Health Service Act (PHSA), Part 7 of the Employee Retirement
Income Security Act of 1974 (ERISA), and Chapter 100 of the Internal Revenue CodeIncome Security Act of 1974 (ERISA), and Chapter 100 of the Internal Revenue Code (IRC). (IRC).
Bernadette Fernandez
Although the health insurance provisions in these statutes are substantively similar, the Although the health insurance provisions in these statutes are substantively similar, the
Specialist in Health Care
Financing
differences reflect, in part, the applicability of each statute to different types of private plans. The differences reflect, in part, the applicability of each statute to different types of private plans. The
PHSA’PHSA's provisions apply broadly across private plans, whereas ERISA and the IRC focus s provisions apply broadly across private plans, whereas ERISA and the IRC focus

primarily on group plans. The Departments of Health and Human Services (HHS), Labor, and the primarily on group plans. The Departments of Health and Human Services (HHS), Labor, and the
Katherine M. Kehres
Treasury—given their overlapping jurisdiction over private coverage—coordinate enforcement Treasury—given their overlapping jurisdiction over private coverage—coordinate enforcement
Analyst in Health Care
efforts with respect to these private health insurance requirements.efforts with respect to these private health insurance requirements.
Financing

Federal requirements on private health insurance may apply to large-group, small-group, self-Federal requirements on private health insurance may apply to large-group, small-group, self-
insured, and/or insured, and/or non-groupnongroup plans. Federal requirements do not apply uniformly to all types of plans. Federal requirements do not apply uniformly to all types of

health plans.health plans.
The selected requirements discussed in this report are grouped into the following categories:The selected requirements discussed in this report are grouped into the following categories:
 Obtaining Obtaining coverage, which refers to consumers, which refers to consumers’' eligibility for coverage eligibility for coverage
 Keeping Keeping coverage, which refers to consumers, which refers to consumers’' ability to maintain their coverage once enrolled ability to maintain their coverage once enrolled
 Health Health insurance premiums, which refers to the amounts consumers pay for health insurance, which refers to the amounts consumers pay for health insurance
 Covered Covered benefits, which refers to the benefits that plans cover (including services such as physician visits , which refers to the benefits that plans cover (including services such as physician visits
and items such as prescription drugs)and items such as prescription drugs)
 Enrollee Enrollee cost sharing and plan payment for benefits, which refers to requirements relating to the , which refers to requirements relating to the
amounts the enrollees pay (i.e., deductibles, coinsurance, co-payments) and the plans pay as enrollees use amounts the enrollees pay (i.e., deductibles, coinsurance, co-payments) and the plans pay as enrollees use
covered benefitscovered benefits
 Health Health care provider interactions, which refers to plan and consumer interactions with providers , which refers to plan and consumer interactions with providers
(including specified out-of-network providers)(including specified out-of-network providers)
 Enrollee Enrollee information and appeals, which refers to plan disclosure of certain information to enrollees (and , which refers to plan disclosure of certain information to enrollees (and
applicants) and enrolleesapplicants) and enrollees’' rights regarding appeals of coverage denials rights regarding appeals of coverage denials
 Federal Federal and public reporting requirements, which refers to plan reporting of specified information to the , which refers to plan reporting of specified information to the
federal government and/or the public disclosure of certain information

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Contents
Introduction ..................................................................................................................................... 1
Background ..................................................................................................................................... 1
Types of Private Health Insurance Plans ................................................................................... 1
Certain Plan Variations ....................................................................................................... 2
Regulation of Private Health Plans ........................................................................................... 3
Federal Requirements ...................................................................................................................... 4
Obtaining Coverage .................................................................................................................. 8
Guaranteed Issue ................................................................................................................. 8
Employer Shared Responsibility Provisions ....................................................................... 9
Prohibition on Using Health Status for Eligibility Determinations .................................... 9
Nondiscrimination Based on Genetic Information ........................................................... 10
Extension of Dependent Coverage .................................................................................... 10
Prohibition of Discrimination Based on Salary ................................................................ 10
Waiting Period Limitation ................................................................................................. 10
Keeping Coverage ................................................................................................................... 10
Guaranteed Renewability ................................................................................................... 11
Prohibition on Rescissions ................................................................................................. 11
COBRA Continuation Coverage ........................................................................................ 11
Coverage for Students Who Take a Medically Necessary Leave of Absence .................... 11
Health Insurance Premiums .................................................................................................... 12
Prohibition on Using Health Status as a Rating Factor ..................................................... 12
Rating Restrictions ............................................................................................................ 12
Rate Review ...................................................................................................................... 13
Single Risk Pool ................................................................................................................ 14
Medical Loss Ratio ........................................................................................................... 14
Covered Benefits ..................................................................................................................... 14
Coverage of Essential Health Benefits.............................................................................. 15
Coverage of Preventive Health Services Without Cost Sharing ....................................... 15
Coverage of COVID-19 Vaccinations and Other Qualifying Preventive Services ........... 16
Coverage for Individuals Participating in Approved Clinical Trials ................................. 17
Coverage of Minimum Hospital Stay After Childbirth ..................................................... 17
Mental Health Parity ......................................................................................................... 17
Coverage of Reconstruction After Mastectomy ................................................................ 18
Coverage of Pregnancy-Related Conditions ..................................................................... 19
Prohibition on Coverage Exclusions Based on Preexisting Health Conditions ................ 19
Enrollee Cost Sharing and Plan Payment for Benefits ............................................................ 19
Maximum Annual Limitation on Cost Sharing ................................................................. 20
Minimum Actuarial Value Requirements .......................................................................... 20
Prohibition on Lifetime and Annual Coverage Limits ...................................................... 21
Health Care Provider Interactions ........................................................................................... 21
Preventing Surprise Medical and Air Ambulance Bills .................................................... 21
Continuity of Care............................................................................................................. 22
Services Provided Based on Incorrect Provider Directory Information ........................... 23
Choice of Healthcare Professionals .................................................................................. 23
Nondiscrimination Regarding Health Care Providers ...................................................... 23
Prohibition on Gag Clauses on Price and Quality Information......................................... 24
Enrollee Information and Appeals........................................................................................... 24
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Summary of Benefits and Coverage and Uniform Glossary ............................................. 24
Advanced Explanation of Benefits ................................................................................... 25
Plan Identification Card Information ................................................................................ 25
Price Comparison Tool ...................................................................................................... 25
Provider Directory Requirements ..................................................................................... 26
Disclosure of Patient Protections Against Balance Billing ............................................... 26
Information on Prescription Drugs ................................................................................... 26
Disclosure to Enrollees of Individual Market Coverage ................................................... 27
Appeals Process and External Review .............................................................................. 27
Federal and Public Reporting Requirements ........................................................................... 27
Reporting Requirements Regarding Quality of Care ........................................................ 27
Reporting Requirements Regarding Air Ambulances ....................................................... 28
Reporting Requirements Regarding Pharmacy Benefits and Drug Costs ......................... 29
Transparency in Coverage ................................................................................................ 29

Tables
Table 1. Applicability of Selected Federal Requirements to
Private Health Insurance Plans ..................................................................................................... 5

Contacts
Author Information ........................................................................................................................ 30

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Introduction
federal government and/or the public disclosure of certain information

Introduction

A majority of Americans have private health insurance. Private health insurance plans must A majority of Americans have private health insurance. Private health insurance plans must
comply with requirements at both the state and federal levels, where applicable.comply with requirements at both the state and federal levels, where applicable.
This report organizes and examines selected federal statutory requirements applicable to private This report organizes and examines selected federal statutory requirements applicable to private
health insurance plans. The first part of this report provides background information about the health insurance plans. The first part of this report provides background information about the
types of private health insurance plans and the regulation of such plans. The second part types of private health insurance plans and the regulation of such plans. The second part
summarizes selected federal requirements and indicates each requirementsummarizes selected federal requirements and indicates each requirement’'s applicability to one or s applicability to one or
more of the following types of private health plans: large group, small group, self-insured, and more of the following types of private health plans: large group, small group, self-insured, and
non-group.nongroup. Table 1 summarizes the applicability of federal statutory requirements across those summarizes the applicability of federal statutory requirements across those
plan types. The selected requirements are grouped under the following categories: obtaining plan types. The selected requirements are grouped under the following categories: obtaining
coverage, keeping coverage, health insurance premiums, covered benefits, enrollee cost sharing coverage, keeping coverage, health insurance premiums, covered benefits, enrollee cost sharing
and plan payment for benefits, health care provider interactions, enrollee information and appeals, and plan payment for benefits, health care provider interactions, enrollee information and appeals,
and federal and public reporting requirements.and federal and public reporting requirements.
Many of the federal requirements described in this report were established under the Patient Many of the federal requirements described in this report were established under the Patient
Protection and Affordable Care Act (ACA; P.L. 111-148, as amended). However, some were Protection and Affordable Care Act (ACA; P.L. 111-148, as amended). However, some were
established under other federal laws. For example, a number of market reforms were first enacted established under other federal laws. For example, a number of market reforms were first enacted
via the Health Insurance Portability and Accountability Act (HIPAA; P.L. 104-191via the Health Insurance Portability and Accountability Act (HIPAA; P.L. 104-191).¹ Certain).1 Over time,
certain private health insurance laws have addressed specific topics, such as mental health parity, private health insurance laws have addressed specific topics, such as mental health parity,2
2 rather than a range of market reforms. Recently, the No Surprises Act, part of the Consolidated rather than a range of market reforms. Recently, the No Surprises Act, part of the Consolidated
Appropriations Act, 2021 (P.L. 116-260), included numerous new private health insurance Appropriations Act, 2021 (P.L. 116-260), included numerous new private health insurance
requirements, primarily requirements, primarily as related to surprise billing.related to surprise billing.3
Background
3

A companion to this report is CRS Report R47507, Private Health Insurance: A Primer, which provides further explanations of key concepts related to the provision of health insurance, as well as enrollment and premium data.

Background Types of Private Health Insurance Plans
Broadly, private health insurance includes Broadly, private health insurance includes group plans (largely made up of (largely made up of employer-sponsored
insurance) and ) and non-groupnongroup plans (i.e., plans a consumer purchases directly from an insurer). (i.e., plans a consumer purchases directly from an insurer).
Federal requirements on private health insurance may apply to some or all of several types of Federal requirements on private health insurance may apply to some or all of several types of
group plans (explained below) and/or to group plans (explained below) and/or to non-groupnongroup plans. plans.
Group plans refer to health benefits provided by employers and other entities (e.g., unions, Group plans refer to health benefits provided by employers and other entities (e.g., unions,
associations) that sponsor such benefits. These plan sponsors can purchase coverage in the associations) that sponsor such benefits. These plan sponsors can purchase coverage in the group
market from state-licensed insurers and offer it to their employees (and their employees from state-licensed insurers and offer it to their employees (and their employees’
' dependents). Health plans obtained this way are referred to as fully insured. The group market is dependents). Health plans obtained this way are referred to as fully insured. The group market is

1 Some Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended) provisions were amendments or
expansions of Health Insurance Portability and Accountability Act (HIPAA; P.L. 104-191) private health insurance
provisions.
2 See, for example, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008
(P.L. 110-343).
3 Requirements summarized in this report are not grouped according to the laws establishing them. In this report, the
term surprise billing refers to specified situations where an individual is unknowingly, and potentially unavoidably,
treated by a provider outside of the consumer’s health insurance plan network and, as a result, unexpectedly receives a
larger bill than the individual would have received if the provider had been in the plan network. A consumer may be
surprised to receive larger-than-expected medical bills for other reasons; for example, the surprise component may arise
because a consumer misunderstands the terms of his or her health insurance policy and receives a bill for an unexpected
amount. Such other reasons generally are outside the scope of this report and are not included in this report’s usage of
the term surprise billing.
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Federal Requirements on Private Health Insurance Plans

divided into segments based on size: the small-group market and the large-group market. For divided into segments based on size: the small-group market and the large-group market. For
purposes of federal requirements that apply to the group market, states may elect to define purposes of federal requirements that apply to the group market, states may elect to define small
groups or employers as those with 50 or fewer individuals (e.g., employees) or groups with 100 groups or employers as those with 50 or fewer individuals (e.g., employees) or groups with 100
or fewer individuals. The definition for or fewer individuals. The definition for large group builds on the small-group definition; a large group builds on the small-group definition; a large
group has at least 51 individuals or at least 101 individuals, depending on which small-group group has at least 51 individuals or at least 101 individuals, depending on which small-group
definition a given state uses.definition a given state uses.
Instead of purchasing group plans from insurers, plan sponsors may set aside funds and pay for Instead of purchasing group plans from insurers, plan sponsors may set aside funds and pay for
health benefits directly; that is, they may health benefits directly; that is, they may self-insure. This alternative approach to providing health . This alternative approach to providing health
benefits means that such sponsors bear the risk of covering the medical expenses generated by the benefits means that such sponsors bear the risk of covering the medical expenses generated by the
individuals covered under the self-insured plan. Groups of any size may self-insure, and federal individuals covered under the self-insured plan. Groups of any size may self-insure, and federal
requirements on self-insured plans generally do not depend on group size.requirements on self-insured plans generally do not depend on group size.
The non-group The nongroup market, also called the market, also called the individual market, is where consumers may purchase a , is where consumers may purchase a
health plan for themselves and their dependents directly from an insurerhealth plan for themselves and their dependents directly from an insurer (i.e., not through a plan
sponsor). For the most part, . For the most part, non-groupnongroup plans are fully insured, and this report discusses them as plans are fully insured, and this report discusses them as
such.such.4
4 Certain Plan Variations
Certain types of group and Certain types of group and non-groupnongroup plans, and certain other types of private health coverage plans, and certain other types of private health coverage
arrangements, are regulated differently than the types generally described above. Selected arrangements, are regulated differently than the types generally described above. Selected
examples of plan variations are briefly referenced here but otherwise are not included in this examples of plan variations are briefly referenced here but otherwise are not included in this
report.report.
Governmental Employee Plans Governmental Employee Plans: Although federal, state, and other governmental employers may Although federal, state, and other governmental employers may
offer group plans as private sector employers do, certain federal requirements on group plans may offer group plans as private sector employers do, certain federal requirements on group plans may
apply to governmental plans differently or may not apply.apply to governmental plans differently or may not apply.5
Plans Offered by Private Insurers to Enrollees of Public Programs5 Plans Offered by Private Insurers to Enrollees of Public Programs: Some beneficiaries in Some beneficiaries in
public health coverage programs obtain their coverage through commercial insurers contracted by public health coverage programs obtain their coverage through commercial insurers contracted by
those programs (e.g., Medicare Advantage or Medicaid managed care plans). Such plans are those programs (e.g., Medicare Advantage or Medicaid managed care plans). Such plans are
subject to those programssubject to those programs’' requirements rather than to those described in this report. requirements rather than to those described in this report.
Plans Offered on the Health Insurance Exchanges: The non-group Plans Offered on the Health Insurance Exchanges: The nongroup and small-group markets and small-group markets
include plans sold on and off the include plans sold on and off the health insurance exchanges. The exchanges are government-run . The exchanges are government-run
marketplaces that facilitate the purchase of private health insurance plans called marketplaces that facilitate the purchase of private health insurance plans called qualified health
plans (QHPs). The QHPs must meet all requirements applicable to the (QHPs). The QHPs must meet all requirements applicable to the non-groupnongroup or small-group or small-group
market segments, plus additional requirements specific to the exchanges. This report does not market segments, plus additional requirements specific to the exchanges. This report does not
include QHP-specific requirements.include QHP-specific requirements.⁶6
Exempted Health Coverage ArrangementsHealth Coverage Arrangements: Certain types of plans meet a federal definition of Certain types of plans meet a federal definition of
health insurance (i.e., they meet the federal definition of health insurance coverage or group health insurance (i.e., they meet the federal definition of health insurance coverage or group
health plan) but are exempt from compliance with some or all federal health insurance health plan) but are exempt from compliance with some or all federal health insurance

4 An exception is discussed in the student health insurance coverage section in CRS Report R46003, Applicability of
Federal Requirements to Selected Health Coverage Arrangements.
5 For more information, see CRS Report R43922, Federal Employees Health Benefits (FEHB) Program: An Overview,
and the self-insured, nonfederal governmental plans section in CRS Report R46003, Applicability of Federal
Requirements to Selected Health Coverage Arrangements.
6 For more information, see CRS Report R44065, Overview of Health Insurance Exchanges.
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requirements that otherwise would be applicablerequirements that otherwise would apply. Such plans include, for example, . Such plans include, for example, grandfathered
plans, plans, excepted benefit plans, and plans, and short-term, limited--duration insurance plans. plans.⁷7
Regulation of Private Health Plans
States are the primary regulators of insurers, as codified by the 1945 McCarran-Ferguson Act States are the primary regulators of insurers, as codified by the 1945 McCarran-Ferguson Act
(P.L. 79-15).(P.L. 79-15).88 Each state requires insurers to be licensed in order to sell health plans in the state, Each state requires insurers to be licensed in order to sell health plans in the state,
and each state has a unique set of requirements that apply to insurers and the plans they offer. and each state has a unique set of requirements that apply to insurers and the plans they offer.
Each stateEach state’'s health insurance requirements are broad in scope and address a variety of issues, and s health insurance requirements are broad in scope and address a variety of issues, and
requirements vary greatly from state to state. State requirements have changed over time in requirements vary greatly from state to state. State requirements have changed over time in
response to shifting priorities about regulation, the evolving health care landscape, and the response to shifting priorities about regulation, the evolving health care landscape, and the
implementation of federal policies.implementation of federal policies.
Health plans offered by state-licensed insurers are subject to state health insurance requirements. Health plans offered by state-licensed insurers are subject to state health insurance requirements.
Because self-insured plans are financed directly by the plan sponsor, such plans generally are not Because self-insured plans are financed directly by the plan sponsor, such plans generally are not
subject to such requirements.subject to such requirements.
In addition to states, the federal government regulates state-licensed insurers and the plans they In addition to states, the federal government regulates state-licensed insurers and the plans they
offer. Federal health insurance requirements typically follow the model of federalism: federal law offer. Federal health insurance requirements typically follow the model of federalism: federal law
establishes standards, and states are primarily responsible for monitoring compliance with and establishes standards, and states are primarily responsible for monitoring compliance with and
enforcement of those standards. Generally, the federal standards establish a minimum level of enforcement of those standards. Generally, the federal standards establish a minimum level of
requirements (requirements (federal floor) and states may impose additional requirements on insurers and the ) and states may impose additional requirements on insurers and the
plans they offer, provided the state requirements neither conflict with federal law nor prevent the plans they offer, provided the state requirements neither conflict with federal law nor prevent the
implementation of federal requirements. For example, the federal implementation of federal requirements. For example, the federal "“Rating Restrictions”
" requirement provides that certain types of health plans may vary premiums by only four factors—requirement provides that certain types of health plans may vary premiums by only four factors—
type of coverage (i.e., self-only or family), geographic rating area, tobacco use, and age. Some type of coverage (i.e., self-only or family), geographic rating area, tobacco use, and age. Some
states have expanded this requirement by prohibiting issuers from varying premiums by tobacco states have expanded this requirement by prohibiting issuers from varying premiums by tobacco
use and age, though no states are allowed to permit these types of plans to vary premiums by any use and age, though no states are allowed to permit these types of plans to vary premiums by any
additional factors.additional factors.
The federal government also regulates self-insured plans, as part of federal oversight of The federal government also regulates self-insured plans, as part of federal oversight of
employment-based benefits. Federal requirements applicable to self-insured plans often are employment-based benefits. Federal requirements applicable to self-insured plans often are
established in tandem with requirements on fully insured plans and state-licensed issuers. established in tandem with requirements on fully insured plans and state-licensed issuers.
Nonetheless, fewer federal requirements overall apply to self-insured plans compared with fully Nonetheless, fewer federal requirements overall apply to self-insured plans compared with fully
insured plans.insured plans.
Federal requirements for health plans are codified primarily in three statutes: Title XXVII of the Federal requirements for health plans are codified primarily in three statutes: Title XXVII of the
Public Health Service Act (PHSA), Part 7 of the Employee Retirement Income Security Act of Public Health Service Act (PHSA), Part 7 of the Employee Retirement Income Security Act of
1974 (ERISA), and Chapter 100 of the Internal Revenue Code (IRC). Although the health 1974 (ERISA), and Chapter 100 of the Internal Revenue Code (IRC). Although the health
insurance provisions in these statutes are substantively similar, the differences reflect, in part, the insurance provisions in these statutes are substantively similar, the differences reflect, in part, the
applicability of each statute to different types of private plans. The PHSAapplicability of each statute to different types of private plans. The PHSA’'s provisions apply s provisions apply
broadly across private plans, whereas ERISA and the IRC focus primarily on group plans. The broadly across private plans, whereas ERISA and the IRC focus primarily on group plans. The
Departments of Health and Human Services (HHS), Labor, and the Treasury—given their Departments of Health and Human Services (HHS), Labor, and the Treasury—given their
overlapping jurisdiction over private coverage—coordinate enforcement efforts with respect to overlapping jurisdiction over private coverage—coordinate enforcement efforts with respect to
these private health insurance requirements.9

7 For more information on these and other types of plans, see CRS Report R46003, Applicability of Federal
Requirements to Selected Health Coverage Arrangements.
8 15 U.S.C. §§1011 et seq. For simplicity, this report generally uses the term insurers to include insurance carriers or
issuers and other state-licensed firms.
9 With respect to health insurers, the Public Health Service Act (PHSA) allows states to be the primary enforcers of the
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Federal Requirements
these private health insurance requirements.⁹ Federal Requirements This report focuses on descriptions of statutory private health insurance requirements on major This report focuses on descriptions of statutory private health insurance requirements on major
medical plans and incorporates references to certain regulatory and sub-regulatory activity where medical plans and incorporates references to certain regulatory and sub-regulatory activity where
necessary to understand key components of the requirements.necessary to understand key components of the requirements.1010 In general, this report does not In general, this report does not
discuss implementation of federal requirements. However, given that Congress recently enacted discuss implementation of federal requirements. However, given that Congress recently enacted
surprise billing and transparency requirements and the Secretaries of HHS, Labor, and the surprise billing and transparency requirements and the Secretaries of HHS, Labor, and the
Treasury were in the process of implementing many of those requirements at the time of this Treasury were in the process of implementing many of those requirements at the time of this
report’report's publication, the implementation of recently enacted requirements is discussed, where s publication, the implementation of recently enacted requirements is discussed, where
appropriate.appropriate.
For the most part, this report focuses on federal requirements applicable to insurers only, insurers For the most part, this report focuses on federal requirements applicable to insurers only, insurers
and self-insured plan sponsors (e.g., employers) in their offering of coverage, and/or on the plans self-insured plan sponsors (e.g., employers) in their offering of coverage, and/or on the plans
themselves.themselves.1111 Selected requirements specific to employers are included to the extent that the Selected requirements specific to employers are included to the extent that the
requirements are particularly relevant to the topics discussed in this report (e.g., requirements are particularly relevant to the topics discussed in this report (e.g., "“COBRA
Continuation Coverage”" in the in the "“Keeping Coverage”" section). section).¹² 12
The federal requirements described in this report are grouped into the following categories: The federal requirements described in this report are grouped into the following categories:
obtaining coverage, keeping coverage, health insurance premiums, covered benefits, cost-sharing obtaining coverage, keeping coverage, health insurance premiums, covered benefits, cost-sharing
limits, requirements related to health care providers, enrollee information and appeals, and federal limits, requirements related to health care providers, enrollee information and appeals, and federal
and public reporting requirements. Each category of requirements begins with brief, contextual and public reporting requirements. Each category of requirements begins with brief, contextual
information about that set of requirements. Some requirements address more than one of these information about that set of requirements. Some requirements address more than one of these
categories. For example, the requirement categories. For example, the requirement "“Nondiscrimination Based on Genetic Information”
" relates to obtaining coverage, health insurance premiums, and coverage of preexisting relates to obtaining coverage, health insurance premiums, and coverage of preexisting
conditions). For the sake of simplicity, these types of crosscutting requirements generally are conditions). For the sake of simplicity, these types of crosscutting requirements generally are
discussed only in the most relevant category (in this case, discussed only in the most relevant category (in this case, "“Obtaining Coverage”).
"). Federal requirements do not apply uniformly to all types of health plans. For example, plans Federal requirements do not apply uniformly to all types of health plans. For example, plans
offered in the offered in the non-groupnongroup and small-group markets must comply with the federal requirement to and small-group markets must comply with the federal requirement to
cover the essential health benefits (EHB; see cover the essential health benefits (EHB; see "“Coverage of Essential Health Benefits”)"); however, ; however,
plans offered in the large-group market and self-insured plans do not have to comply with this plans offered in the large-group market and self-insured plans do not have to comply with this
requirementrequirement. Table 1 lists the specific types of plans to which the federal requirements described lists the specific types of plans to which the federal requirements described
in this report apply: large group, small group, self-insured, and in this report apply: large group, small group, self-insured, and non-groupnongroup. Summary descriptions . Summary descriptions
of the federal requirements follow the table.

federal private health insurance requirements, but the Secretary of the Department of Health and Human Services
(HHS) assumes this responsibility if the Secretary has determined that a state has failed to “substantially enforce” the
federal PHSA provisions. For more information on enforcement of private health insurance requirements, see CRS
Report R46637, Federal Private Health Insurance Market Reforms: Legal Framework and Enforcement.
10 Most people with private health insurance have a major medical plan. Major medical plans provide comprehensive
health benefits compared with limited benefit plans, although the specific covered benefits may vary across major
medical plans. One example of a limited benefit plan is an excepted benefit plan, such as a dental-only or vision-only
plan. For more information on these and other types of plans, see CRS Report R46003, Applicability of Federal
Requirements to Selected Health Coverage Arrangements.
11 In this report, references to plans include applicable group health plans and insurers.
12 This report does not include the full range of employer-focused requirements that may have some relevance to group
health plans (e.g., fiduciary requirements).
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Table 1. Applicability of Selected Federal Requirements to
Private Health Insurance Plans
Groupb
Fully Insuredd
Large
Small
Self-
Non-
U.S. Codea
Provision
Groupf Groupf Insurede
groupc
Obtaining Coverage
42 U.S.C.
Guaranteed Issue
√
√
N.A.
√
§300gg-1
26 U.S.C.
Employer Shared Responsibility Provisions
√
N.A.g
√g
N.A.
§4980H
of the federal requirements follow the table. Table 1. Applicability of Selected Federal Requirements to Private Health Insurance Plans U.S. Code^a

Provision

Group^b Nongroup^c Fully Insured^d Self-Insured^e Large Group^f Small Group^f

Obtaining Coverage

42 U.S.C. §300gg-1

Guaranteed Issue

√

√

N.A.

√

26 U.S.C. §4980H

Employer Shared Responsibility Provisions

√

N.A.^g √^g

N.A.

42 U.S.C. §300gg-4(a)

Prohibition on Using Health Status for Eligibility Determinations

√

√

√

√

42 U.S.C. §300gg-3, 4

42 U.S.C.
Prohibition on Using Health Status for
√
√
√
√
§300gg-4(a)
Eligibility Determinations
42 U.S.C.
Nondiscrimination Based on Genetic Nondiscrimination Based on Genetic
Information

√

√

√

√

√
√
√
√
§300gg-3, 4
Information
42 U.S.C.
Extension of Dependent Coverage
√
√
√
√
§300gg-14
42 U.S.C.
Prohibition of Discrimination Based on
√h
√h
√h
N.A.
§300gg-16;
Salary
26 U.S.C.
§105(h)
42 U.S.C. §300gg-14

Extension of Dependent Coverage

√

√

√

√

42 U.S.C. §300gg-16;

26 U.S.C. §105(h)

Prohibition of Discrimination Based on Salary

√^h √^h √^h

N.A.

42 U.S.C. §300gg-7

Waiting Period Limitation

√

√

√

N.A.

Keeping Coverage

42 U.S.C.
Waiting Period Limitation
√
√
√
N.A.
§300gg-7
Keeping Coverage
42 U.S.C.
Guaranteed Renewability
√
√
N.A.
√
§300gg-2
42 U.S.C.
42 U.S.C. §300gg-2

Guaranteed Renewability

√

√

N.A.

√

42 U.S.C. §300gg-12

Prohibition on RescissionsProhibition on Rescissions
√
√
√
√
§300gg-12

√

√

√

√

29 U.S.C. §1161- §1168

COBRA Continuation Coverageⁱ

√

√^j √^j

N.A.

42 U.S.C. §300gg-28

29 U.S.C.
COBRA Continuation Coveragei
√
√j
√j
N.A.
§1161- §1168
42 U.S.C.
Coverage for Students Who Take a
√
√
√
√
§300gg-28
Medically Necessary Leave of Absence
Health Insurance Premiums
42 U.S.C.
Prohibition on Using Health Status as a
√
√
√
√k
§300gg-4(b)
Rating Factor
42 U.S.C.
Rating Restrictions
N.A.
√
N.A.
√
§300gg
42 U.S.C.
Rate Review
N.A.
√
N.A.
√
§300gg-94
42 U.S.C.
Single Risk Pool
N.A.
√
N.A.
√
§18032
42 U.S.C.
Medical Loss Ratio
√
√
N.A.
√
§300gg-18
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Groupb
Fully Insuredd
Large
Small
Self-
Non-
U.S. Codea
Provision
Groupf Groupf Insurede
groupc
Covered Benefits
42 U.S.C.
Coverage of Essential Health Benefits
§300gg-6(a);
N.A.
√
N.A.
√
42 U.S.C.
§18022
42 U.S.C.
Coverage for Students Who Take a Medically Necessary Leave of Absence

√

√

√

√

Health Insurance Premiums

42 U.S.C. §300gg-4(b)

Prohibition on Using Health Status as a Rating Factor

√

√

√

√^k

42 U.S.C. §300gg

Rating Restrictions

N.A.

√

N.A.

√

42 U.S.C. §300gg-94

Rate Review

N.A.

√

N.A.

√

42 U.S.C. §18032

Single Risk Pool

N.A.

√

N.A.

√

42 U.S.C. §300gg-18

Medical Loss Ratio

√

√

N.A.

√

Covered Benefits

42 U.S.C. §300gg-6(a);

42 U.S.C. §18022

Coverage of Essential Health Benefits

N.A.

√

N.A.

√

42 U.S.C. §300gg-13

Coverage of Preventive Health Services Without Cost Sharing

√

√

√

√

Coverage of Preventive Health Services
§300gg-13
Without Cost Sharing
√
√
√
√
42 U.S.C.
Coverage of COVID-19 Vaccinations and
√
√
√
√
§300gg-13,
Other Qualifying Preventive Services
Stat. Note.
42 U.S.C. §300gg-13,

Stat. Note.

Coverage of COVID-19 Vaccinations and Other Qualifying Preventive Services

√

√

√

√

42 U.S.C. §300gg-8

Coverage for Individuals Participating in Approved Clinical Trials

√

√

√

√

42 U.S.C. §300gg-25

42 U.S.C.
Coverage for Individuals Participating in
√
√
√
√
§300gg-8
Approved Clinical Trials
42 U.S.C.
Coverage of Minimum Hospital Stay After Coverage of Minimum Hospital Stay After
Childbirth

√

√

√

√

42 U.S.C. §300gg-26

Mental Health Parity

√

√^l √^l

√

42 U.S.C. §300gg-27

§300gg-25
Childbirth
√
√
√
√
42 U.S.C.
Mental Health Parity
√
√l
√l
√
§300gg-26
42 U.S.C.
Coverage of Reconstruction After Coverage of Reconstruction After
√
√
√
√
§300gg-27
Mastectomy
Mastectomy

√

√

√

√

42 U.S.C. §2000e(k)^m

Coverage of Pregnancy-Related Conditions

√ⁿ √ⁿ √ⁿ

N.A.

42 U.S.C. §300gg-3

42 U.S.C.
Coverage of Pregnancy-Related Conditions
√n
√n
√n
N.A.
§2000e(k)m
42 U.S.C.
Prohibition on Coverage Exclusions Based Prohibition on Coverage Exclusions Based
√
√
√
√
§300gg-3
on Preexisting Health Conditions
on Preexisting Health Conditions

√

√

√

√

Enrollee Cost-Sharing and Plan Payment for Benefits
42 U.S.C.

42 U.S.C. §300gg-6(b);

42 U.S.C. §18022

Maximum Annual Limitation on Cost SharingMaximum Annual Limitation on Cost Sharing
√
√
√
√
§300gg-6(b);

√

√

√

√

42 U.S.C. §300gg-6(b);

42 U.S.C.
§18022
42 U.S.C.
42 U.S.C. §18022 Minimum Actuarial Value RequirementsMinimum Actuarial Value Requirements
N.A.
√
N.A.
√
§300gg-6(b);
42 U.S.C.
§18022

N.A.

√

N.A.

√

42 U.S.C. §300gg-11

Prohibition on Lifetime and Annual Coverage Limits

√

√

√

√

Health Care Provider Interactions

42 U.S.C. §300gg-111, 112

42 U.S.C.
Prohibition on Lifetime and Annual
√
√
√
√
§300gg-11
Coverage Limits
Health Care Provider Interactions
42 U.S.C.
Preventing Surprise Medical and Air Preventing Surprise Medical and Air
√
√
√
√
§300gg-111,
Ambulance Bil s
112
42 U.S.C.
Continuity of Care
√
√
√
√
§300gg-113
Ambulance Bills

√

√

√

√

42 U.S.C. §300gg-113

Continuity of Care

√

√

√

√

42 U.S.C. §300gg-115(b)

Services Provided Based on Incorrect Provider Directory Information

√

√

√

√

42 U.S.C. §300gg-117

Choice of Health Care Professionals

√

√

√

√

42 U.S.C.
Services Provided Based on Incorrect
√
√
√
√
§300gg-115(b)
Provider Directory Information
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Groupb
Fully Insuredd
Large
Small
Self-
Non-
U.S. Codea
Provision
Groupf Groupf Insurede
groupc
42 U.S.C.
Choice of Healthcare Professionals
√
√
√
√
§300gg-117
42 U.S.C.
Nondiscrimination Regarding Health Care
√
√
√
√
§300gg-5
Providers
42 U.S.C.
42 U.S.C. §300gg-5

Nondiscrimination Regarding Health Care Providers

√

√

√

√

42 U.S.C. §300gg-119

Prohibition on Gag Clauses on Price and Prohibition on Gag Clauses on Price and
√
√
√
√
§300gg-119
Quality Information
Quality Information

√

√

√

√

Enrollee Information and Appeals
42 U.S.C. 42 U.S.C.
§300gg-15 Summary of Benefits and Coverage and Summary of Benefits and Coverage and
√
√
√
√
§300gg-15
Uniform Glossary
Uniform Glossary

√

√

√

√

42 U.S.C. §300gg-111(f)

Advanced Explanation of Benefits^o

√

√

√

√

42 U.S.C. §300gg-111(e)

42 U.S.C.
Advanced Explanation of Benefitso
√
√
√
√
§300gg-111(f)
42 U.S.C.
Plan Identification Card InformationPlan Identification Card Information
√
√
√
√
§300gg-111(e)

√

√

√

√

42 U.S.C. §300gg-114;

42 U.S.C. §300gg-15a^p

Price Comparison Tool

√

√

√

√

42 U.S.C.
Price Comparison Toolo
√
√
√
√
§300gg-114;
42 U.S.C. 42 U.S.C.
§300gg-15ap
42 U.S.C.
§300gg-115(a) Provider Directory RequirementsProvider Directory Requirements
√
√
√
√
§300gg-115(a)

√

√

√

√

42 U.S.C. §300gg-115(c)

Disclosure of Patient Protections Against Balance Billing

√

√

√

√

42 U.S.C. §300gg-19b

42 U.S.C.
Disclosure of Patient Protections Against
√
√
√
√
§300gg-115(c)
Balance Bil ing
42 U.S.C.
Information on Prescription DrugsInformation on Prescription Drugs
√
√
√
√
§300gg-19b
42 U.S.C.
Disclosure to Enrol ees of Individual Market
N.A.
N.A.
N.A.
√
§300gg-46
Coverage
42 U.S.C.
Appeals Process and External Review
√
√
√
√
§300gg-19

√

√

√

√

42 U.S.C. §300gg-46

Disclosure to Enrollees of Individual Market Coverage

N.A.

N.A.

N.A.

√

42 U.S.C. §300gg-19

Appeals Process and External Review

√

√

√

√

Federal and Public Reporting Requirements

42 U.S.C. §300gg-17

Reporting Requirements Regarding Quality of Care

√

√

√

√

42 U.S.C.
Reporting Requirements Regarding Quality
√
√
√
√
§300gg-17
of Care
42 U.S.C.
Reporting Requirements Regarding Air
√
√
√
√
§300gg-118
Ambulanceso
42 U.S.C. §300gg-118 Reporting Requirements Regarding Air Ambulances^o

√

√

√

√

42 U.S.C. §300gg-120

Reporting Requirements Regarding Pharmacy Benefits and Drug Costs

√

√

√

√

42 U.S.C. 300gg-15a^q Transparency in Coverage^o

√

√

√

√

42 U.S.C.
Reporting Requirements Regarding
√
√
√
√
§300gg-120
Pharmacy Benefits and Drug Costs
42 U.S.C.
Transparency in Coverageo
√
√
√
√
300gg-15aq
Source: Congressional Research Service analysis of federal statutes.Congressional Research Service analysis of federal statutes.
Notes: N.A. indicates the requirement is not applicable to that type of health plan. The requirements listed in N.A. indicates the requirement is not applicable to that type of health plan. The requirements listed in
the table do not comprise a comprehensive list of all federal requirements and standards that apply to all health the table do not comprise a comprehensive list of all federal requirements and standards that apply to all health
plans.plans.
a. a. Some requirements listed in this table also may be found in other sections of the Some requirements listed in this table also may be found in other sections of the U.S. Code.
Congressional Research Service

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Federal Requirements on Private Health Insurance Plans

b. b. Health insurance may be provided to a group of people that are drawn together by an employer or other Health insurance may be provided to a group of people that are drawn together by an employer or other
organization, such as a trade union. Generally, such groups form for a purpose other than obtaining organization, such as a trade union. Generally, such groups form for a purpose other than obtaining
insurance, such as employment. Insurance provided to a group is referred to as insurance, such as employment. Insurance provided to a group is referred to as group coverage or or group
insurance. With respect to group coverage, the entity that purchases health insurance on behalf of a group is . With respect to group coverage, the entity that purchases health insurance on behalf of a group is
referred to as the referred to as the plan sponsor..
c. c. Consumers who are not associated with a group can obtain health coverage by purchasing it directly from Consumers who are not associated with a group can obtain health coverage by purchasing it directly from
an insurer in the an insurer in the non-groupnongroup (or (or individual) health insurance market.) health insurance market.
d. d. A A fully insured health plan is one in which the plan sponsor purchases health coverage from a state-licensed is one in which the plan sponsor purchases health coverage from a state-licensed
insurer; the insurer assumes the risk of paying the medical claims of the sponsorinsurer; the insurer assumes the risk of paying the medical claims of the sponsor’s enrol ees.
e. 's enrollees. e. Self-insured plans refer to health coverage that is provided directly by the organization sponsoring coverage refer to health coverage that is provided directly by the organization sponsoring coverage
for its members (e.g., a firm providing health benefits to its employees). Such organizations set aside funds for its members (e.g., a firm providing health benefits to its employees). Such organizations set aside funds
and pay for health benefits directly. Under self-insurance, the organization bears the risk for covering and pay for health benefits directly. Under self-insurance, the organization bears the risk for covering
medical claims. In general, the size of a self-insured employer does not affect the applicability of federal medical claims. In general, the size of a self-insured employer does not affect the applicability of federal
requirements.requirements.
f. f.
States may elect to define States may elect to define small groups as groups with 50 or fewer individuals or as groups with 100 or as groups with 50 or fewer individuals or as groups with 100 or
fewer individuals. The definition for fewer individuals. The definition for large group builds on the small-group definition; a large group would builds on the small-group definition; a large group would
have at least 51 individuals or at least 101 individuals, depending on which small-group definition a given have at least 51 individuals or at least 101 individuals, depending on which small-group definition a given
state uses.state uses.
g. g. Employers with fewer than 50 employees are not required to comply with the employer shared Employers with fewer than 50 employees are not required to comply with the employer shared
responsibility provisions.responsibility provisions.
h. Ful y h. Fully insured plans are subject to the nondiscrimination requirement codified at 42 U.S.C. §300gg-16 (and insured plans are subject to the nondiscrimination requirement codified at 42 U.S.C. §300gg-16 (and
incorporated by reference into the Employee Retirement Income Security Act of 1974 and the Internal incorporated by reference into the Employee Retirement Income Security Act of 1974 and the Internal
Revenue Code). Self-insured plans are subject to the nondiscrimination requirement codified at 26 U.S.C. Revenue Code). Self-insured plans are subject to the nondiscrimination requirement codified at 26 U.S.C.
§105(h). The nondiscrimination requirement for §105(h). The nondiscrimination requirement for ful yfully insured plans is not in effect as of the date of this insured plans is not in effect as of the date of this
report, but the requirement for self-insured plans is in effect.report, but the requirement for self-insured plans is in effect.
i. i.
COBRA stands for the Consolidated Omnibus Budget Reconciliation Act of 1985 (P.L. 99-272COBRA stands for the Consolidated Omnibus Budget Reconciliation Act of 1985 (P.L. 99-272). j. ).
j.
Employers with fewer than 20 employees are not required to comply with COBRAEmployers with fewer than 20 employees are not required to comply with COBRA’'s coverage continuation s coverage continuation
requirement.requirement.
k. k. As part of this requirement, a plan may establish premium discounts or rebates or may modify cost sharing As part of this requirement, a plan may establish premium discounts or rebates or may modify cost sharing
requirements in return for adherence to a wellness plan. This does not apply to requirements in return for adherence to a wellness plan. This does not apply to non-groupnongroup plans. plans.
l.
Ful y l. Fully insured small-group plans are subject to mental health parity requirements because of the insured small-group plans are subject to mental health parity requirements because of the
incorporation of parity requirements into essential health benefit requirements. Self-insured plans incorporation of parity requirements into essential health benefit requirements. Self-insured plans
sponsored by small employers (50 or fewer employees) are exempt from mental health parity sponsored by small employers (50 or fewer employees) are exempt from mental health parity
requirements.requirements.
m. m. Also see 29 C.F.R. §1604.10 and 29 C.F.R. §1604, Appendix to Part 1604—Questions and Answers on the Also see 29 C.F.R. §1604.10 and 29 C.F.R. §1604, Appendix to Part 1604—Questions and Answers on the
Pregnancy Discrimination Act, P.L. 95-555, 92 Stat. 2076 (1978).Pregnancy Discrimination Act, P.L. 95-555, 92 Stat. 2076 (1978).
n. n. This requirement applies to employers with 15 or more employees, whether the coverage is This requirement applies to employers with 15 or more employees, whether the coverage is ful yfully insured or insured or
self-insured.self-insured.
o. o. This is a recently enacted requirement and, as of the date of this report, This is a recently enacted requirement and, as of the date of this report, enforcementimplementation of some or all aspects of some or all aspects
of this requirement has of this requirement has been deferred.
p. not occurred. p. Also see 45 C.F.R. §147.211.Also see 45 C.F.R. §147.211.
q. q. Also see 45 C.F.R. §147.212.Also see 45 C.F.R. §147.212.
Obtaining Coverage
Requirements in this section relate to consumersRequirements in this section relate to consumers’' eligibility for coverage. eligibility for coverage.
Guaranteed Issue
Plans must comply with the Plans must comply with the guaranteed issue requirement. requirement.1313 In general, plans must accept every In general, plans must accept every
applicant for such coverage, as long as the applicant agrees to the terms and conditions of the applicant for such coverage, as long as the applicant agrees to the terms and conditions of the

13 42 U.S.C. §300gg-1.
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insurance offer (e.g., premium). Plans may restrict enrollment to open and special enrollment insurance offer (e.g., premium). Plans may restrict enrollment to open and special enrollment
periods under specified circumstances; such circumstances differ between periods under specified circumstances; such circumstances differ between non-groupnongroup and group and group
plans.plans.1414 Eligibility for group coverage may depend on meeting a waiting period requirement. Eligibility for group coverage may depend on meeting a waiting period requirement.15
15 Plans that otherwise would be required to offer coverage on a guaranteed-issue basis are allowed Plans that otherwise would be required to offer coverage on a guaranteed-issue basis are allowed
to deny coverage to individuals and employers in certain circumstances, such as when a plan to deny coverage to individuals and employers in certain circumstances, such as when a plan
demonstrates that it does not have the network capacity to deliver services to additional enrollees demonstrates that it does not have the network capacity to deliver services to additional enrollees
or the financial capacity to offer additional coverage.or the financial capacity to offer additional coverage.
Large-group, small-group, and Large-group, small-group, and non-groupnongroup plans are subject to this requirement. plans are subject to this requirement.
Employer Shared Responsibility Provisions
The employer shared responsibility provisions (ESRP), often referred to as the The employer shared responsibility provisions (ESRP), often referred to as the employer
mandate, generally incentivize large employers to offer adequate, affordable health insurance , generally incentivize large employers to offer adequate, affordable health insurance
coverage to their full-time employees and their full-time employeescoverage to their full-time employees and their full-time employees’' dependents. dependents.1616 If an If an
applicable large employer fails to offer health insurance or offers substandard coverage to its applicable large employer fails to offer health insurance or offers substandard coverage to its
employees, the employer may be subject to a penalty.employees, the employer may be subject to a penalty.
This requirement applies to employers with 50 or more employees, whether the coverage is fully This requirement applies to employers with 50 or more employees, whether the coverage is fully
insured or self-insured.insured or self-insured.
Prohibition on Using Health Status for Eligibility Determinations
Plans are prohibited from basing applicant eligibility on Plans are prohibited from basing applicant eligibility on health status-related factors..1717 Such Such
factors include health status, medical condition (including both physical and mental illness), factors include health status, medical condition (including both physical and mental illness),
claims experience, receipt of health care, medical history, genetic information, evidence of claims experience, receipt of health care, medical history, genetic information, evidence of
insurability (including conditions arising out of acts of domestic violence), disability, and any insurability (including conditions arising out of acts of domestic violence), disability, and any
other health status-related factor determined appropriate by the HHS Secretary. (A companion other health status-related factor determined appropriate by the HHS Secretary. (A companion
requirement regarding health nondiscrimination applies to premiums; see requirement regarding health nondiscrimination applies to premiums; see "“Prohibition on Using
Health Status as a Rating Factor,” ," below.)below.)
Large-group, small-group, self-insured, and Large-group, small-group, self-insured, and non-groupnongroup plans are subject to this requirement. Nondiscrimination Based on Genetic Information plans are subject to this requirement.

14 Non-group plans that choose to establish an open enrollment period must apply the same period to plans inside and
outside the health insurance exchanges. The open enrollment period rules applicable to exchanges are codified at
45 C.F.R. §155.410. Group plans must allow enrollment during any time of the year, with an exception for small-group
plans. Small-group plans may limit enrollment to an annual period from November 15 through December 15 of each
year if the plan sponsor does not comply with provisions relating to employer-contribution or group-participation rules,
pursuant to state law; see 45 C.F.R. §147.104(b). Qualifying events for special enrollment periods are defined in §603
of the Employee Retirement Income Security Act of 1974 (ERISA; P.L. 93-406) and in 45 C.F.R. §155.420(d).
15 A waiting period refers to an amount of time that must pass before an individual becomes eligible to enroll under the
terms of the plan. A federal requirement specifically concerning the duration of waiting periods is discussed later in this
report (see “Waiting Period Limitation”).
16 26 U.S.C. §4980H. For more information, see CRS Report R45455, The Affordable Care Act’s (ACA’s) Employer
Shared Responsibility Provisions (ESRP).
17 42 U.S.C. §300gg-4(a).
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Federal Requirements on Private Health Insurance Plans

Nondiscrimination Based on Genetic Information
Plans are prohibited from (1) using genetic information to deny coverage, adjust premiums, or Plans are prohibited from (1) using genetic information to deny coverage, adjust premiums, or
impose a preexisting-condition exclusion; (2) requiring or requesting genetic testing; and (3) impose a preexisting-condition exclusion; (2) requiring or requesting genetic testing; and (3)
collecting or acquiring genetic information for insurance underwriting purposes.collecting or acquiring genetic information for insurance underwriting purposes.¹⁸ 18
Large-group, small-group, self-insured, and Large-group, small-group, self-insured, and non-groupnongroup plans are subject to these requirements. plans are subject to these requirements.
Extension of Dependent Coverage
If a plan offers dependent coverage to children, the plan must make such coverage available to a If a plan offers dependent coverage to children, the plan must make such coverage available to a
child under the age of 26.child under the age of 26.1919 Plans that offer dependent coverage must make coverage available for Plans that offer dependent coverage must make coverage available for
both married and unmarried adult children under the age of 26, but plans do not have to make both married and unmarried adult children under the age of 26, but plans do not have to make
coverage available to the adult childcoverage available to the adult child’'s children or spouse (although a plan may voluntarily choose s children or spouse (although a plan may voluntarily choose
to cover these individuals).to cover these individuals).
Large-group, small-group, self-insured, and Large-group, small-group, self-insured, and non-groupnongroup plans are subject to this requirement. plans are subject to this requirement.
Prohibition of Discrimination Based on Salary
The sponsors of health plans (e.g., employers) are prohibited from establishing eligibility criteria The sponsors of health plans (e.g., employers) are prohibited from establishing eligibility criteria
based on any full-time employeebased on any full-time employee’'s total hourly or annual salary.s total hourly or annual salary.2020 Eligibility rules are not Eligibility rules are not
permitted to discriminate in favor of higher-wage employees. Additionally, sponsors are permitted to discriminate in favor of higher-wage employees. Additionally, sponsors are
prohibited from providing benefits under a plan that discriminates in favor of higher-wage prohibited from providing benefits under a plan that discriminates in favor of higher-wage
employees (i.e., a sponsor must provide all the benefits it provides to higher-wage employees to employees (i.e., a sponsor must provide all the benefits it provides to higher-wage employees to
all other full-time employees).all other full-time employees).
Large-group, small-group, and self-insured plans are subject to this requirement.Large-group, small-group, and self-insured plans are subject to this requirement.
Waiting Period Limitation
Plans are prohibited from establishing waiting periods longer than 90 days.Plans are prohibited from establishing waiting periods longer than 90 days.2121 A A waiting period
refers to the time that must pass before coverage can refers to the time that must pass before coverage can become effectivego into effect for an individual who is for an individual who is
eligible to enroll under the terms of the plan. In general, if an individual can elect coverage that eligible to enroll under the terms of the plan. In general, if an individual can elect coverage that
begins within 90 days of the beginning of the waiting period, the plan complies with this begins within 90 days of the beginning of the waiting period, the plan complies with this
provision.provision.
Large-group, small-group, and self-insured plans are subject to this requirement.Large-group, small-group, and self-insured plans are subject to this requirement.
Keeping Coverage
These requirements relate to consumersThese requirements relate to consumers’' ability to maintain their coverage once enrolled. Guaranteed Renewability ability to maintain their coverage once enrolled.

18 42 U.S.C. §§300gg–3 and 300gg–4, and 45 C.F.R. §§147.110 and 146.121.
19 42 U.S.C. §300gg-14.
20 Fully insured plans are subject to the nondiscrimination requirement codified at 42 U.S.C. §300gg-16 (and
incorporated by reference into ERISA and the Internal Revenue Code). Self-insured plans are subject to the
nondiscrimination requirement codified at 26 U.S.C. §105(h).
21 42 U.S.C. §300gg-7.
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Federal Requirements on Private Health Insurance Plans

Guaranteed Renewability
Guaranteed renewability is a requirement for plans to renew coverage at the option of the is a requirement for plans to renew coverage at the option of the
policyholder or the plan sponsor for policyholder or the plan sponsor for non-groupnongroup plans and group plans, respectively. plans and group plans, respectively.2222 Plans that Plans that
must comply with guaranteed renewability may discontinue the plan only under certain must comply with guaranteed renewability may discontinue the plan only under certain
circumstances. For example, a plan may discontinue coverage if the individual or plan sponsor circumstances. For example, a plan may discontinue coverage if the individual or plan sponsor
fails to pay premiums or if an individual or plan sponsor performs an act that constitutes fraud in fails to pay premiums or if an individual or plan sponsor performs an act that constitutes fraud in
connection with the coverage.connection with the coverage.
Large-group, small-group, and Large-group, small-group, and non-groupnongroup plans are subject to this requirement. plans are subject to this requirement.
Prohibition on Rescissions
Plans generally are prohibited from rescinding coverage; the practice of Plans generally are prohibited from rescinding coverage; the practice of rescission refers to the refers to the
retroactive cancellation of coverage after an enrollee has become sick or injured.retroactive cancellation of coverage after an enrollee has become sick or injured.2323 Plans may Plans may
rescind coverage if an enrollee committed fraud or made an intentional misrepresentation of rescind coverage if an enrollee committed fraud or made an intentional misrepresentation of
material fact, as prohibited by the terms of the plan. Such cancellation of coverage requires a plan material fact, as prohibited by the terms of the plan. Such cancellation of coverage requires a plan
to provide at least 30 calendar daysto provide at least 30 calendar days’' advance notice to the enrollee. advance notice to the enrollee.
Large-group, small-group, self-insured, and Large-group, small-group, self-insured, and non-groupnongroup plans are subject to this requirement. plans are subject to this requirement.
COBRA Continuation Coverage24
Coverage²⁴ Certain employers are required to continue to offer coverage to certain employees and their Certain employers are required to continue to offer coverage to certain employees and their
dependents (dependents (qualified beneficiaries) who otherwise would be ineligible for such coverage because ) who otherwise would be ineligible for such coverage because
of certain circumstances (of certain circumstances (qualifying events).25events).²⁵ Generally, plan sponsors must provide access to Generally, plan sponsors must provide access to
continuation coverage to qualified beneficiaries for up to 18 months (or longer, under certain continuation coverage to qualified beneficiaries for up to 18 months (or longer, under certain
circumstances) following a qualifying event. Beneficiaries may be charged up to 102% of the circumstances) following a qualifying event. Beneficiaries may be charged up to 102% of the
premium for such coverage.premium for such coverage.
This requirement applies to employers with 20 or more employees, whether the coverage is fully This requirement applies to employers with 20 or more employees, whether the coverage is fully
insured or self-insured.insured or self-insured.
Coverage for Students Who Take a Medically Necessary Leave of Absence
Plans are prohibited from terminating the health coverage of an applicable student who takes a Plans are prohibited from terminating the health coverage of an applicable student who takes a
leave of absence (or other change in educational enrollment) from a postsecondary educational leave of absence (or other change in educational enrollment) from a postsecondary educational
institution that causes the student to lose student status for health coverage purposes.institution that causes the student to lose student status for health coverage purposes.2626 The leave The leave
of absence or change in educational enrollment must be medically necessary and must begin of absence or change in educational enrollment must be medically necessary and must begin
while the student is suffering from a severe illness or injury. These requirements are colloquially while the student is suffering from a severe illness or injury. These requirements are colloquially
referred to as referred to as Michelle’'s Law..²⁷ 27
Large-group, small-group, self-insured, and Large-group, small-group, self-insured, and non-groupnongroup plans are subject to this requirement. Health Insurance Premiums plans are subject to this requirement.

22 42 U.S.C. §300gg-2.
23 42 U.S.C. §300gg-12.
24 This requirement was established under Title X of the Consolidated Omnibus Budget Reconciliation Act of 1985
(COBRA; P.L. 99-272). Coverage received under this requirement is typically referred to as COBRA coverage.
25 29 U.S.C. §§1161-1168. An example of a qualifying event is termination from a job.
26 42 U.S.C. §300gg–28.
27 P.L. 110-381.
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Health Insurance Premiums
The following requirements relate to premiums, which are the amounts consumers and others pay The following requirements relate to premiums, which are the amounts consumers and others pay
for health coverage.for health coverage.²⁸28
Prohibition on Using Health Status as a Rating Factor
Plans are prohibited from varying premiums for Plans are prohibited from varying premiums for similarly situated individuals based on the based on the health
status-related factors of the individuals or their dependents.of the individuals or their dependents.2929 Such factors include health status, Such factors include health status,
medical condition (including both physical and mental illness), claims experience, receipt of medical condition (including both physical and mental illness), claims experience, receipt of
health care, medical history, genetic information, evidence of insurability (including conditions health care, medical history, genetic information, evidence of insurability (including conditions
arising out of acts of domestic violence), disability, and any other health status-related factor arising out of acts of domestic violence), disability, and any other health status-related factor
determined appropriate by the HHS Secretary. (A companion requirement regarding health determined appropriate by the HHS Secretary. (A companion requirement regarding health
nondiscrimination applies to eligibility; see nondiscrimination applies to eligibility; see "“Prohibition on Using Health Status for Eligibility
Determinations,” above.)
Determinations," above.) Plans may establish premium discounts or rebates or modify cost-sharing requirements in return Plans may establish premium discounts or rebates or modify cost-sharing requirements in return
for adherence to a wellness program.for adherence to a wellness program.3030 If a wellness program is made available to all similarly If a wellness program is made available to all similarly
situated individuals and either does not provide a reward or provides a reward based solely on situated individuals and either does not provide a reward or provides a reward based solely on
participation, then the program complies with federal law without having to satisfy any additional participation, then the program complies with federal law without having to satisfy any additional
standards. If a program provides a reward based on an individual meeting a certain standard standards. If a program provides a reward based on an individual meeting a certain standard
relating to a health factor, then the program must meet additional requirements specified in relating to a health factor, then the program must meet additional requirements specified in
federal regulations and the reward must be capped at 30% of the cost of employee-only coverage federal regulations and the reward must be capped at 30% of the cost of employee-only coverage
under the plan. However, the Secretaries of HHS, Labor, and the Treasury have discretion to under the plan. However, the Secretaries of HHS, Labor, and the Treasury have discretion to
increase the reward up to 50% of the cost of coverage if the increase is determined to be increase the reward up to 50% of the cost of coverage if the increase is determined to be
appropriate.appropriate.
Large-group, small-group, self-insured, and Large-group, small-group, self-insured, and non-groupnongroup plans are subject to the overall health plans are subject to the overall health
nondiscrimination requirement. Large-group, small-group, and self-insured plans are subject to nondiscrimination requirement. Large-group, small-group, and self-insured plans are subject to
the conditions for providing discounts or rebates for wellness activities.the conditions for providing discounts or rebates for wellness activities.
Rating Restrictions
Plans must use adjusted (or modified) community rating rules to determine premiums.Plans must use adjusted (or modified) community rating rules to determine premiums.3131 Adjusted Adjusted
community rating prohibits the use of health factors in the determination of premiums but allows community rating prohibits the use of health factors in the determination of premiums but allows
premium variation based on other factors. Premiums may vary based on the following four premium variation based on other factors. Premiums may vary based on the following four
factors:32

28 For the sake of simplicity, the use of the term premium in this report broadly applies not only to the final amounts
paid by consumers and others for coverage but also the prices for insurance products that health insurance issuers
determine as they develop final premium amounts.
29 42 U.S.C. §300gg-4(b). For information about identifying similarly situated individuals, see 45 C.F.R. §146.121(d).
30 42 U.S.C. §300gg-4(j).
31 42 U.S.C. §300gg.
32 Federal law allows states to impose additional rating requirements, provided the state requirements neither conflict
with federal law nor prevent the implementation of federal requirements. For more information about state rating
requirements, see Centers for Medicare & Medicaid Services (CMS), Center for Consumer Information & Insurance
Oversight (CCIIO), “Market Rating Reforms: State Specific Rating Variations,” at https://www.cms.gov/CCIIO/
Programs-and-Initiatives/Health-Insurance-Market-Reforms/state-rating.html.
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Federal Requirements on Private Health Insurance Plans

 Type of Enrollmentfactors:³² Type of Enrollment. Plans may vary premiums based on whether only an Plans may vary premiums based on whether only an
individual enrolls in the plan or an individual and dependent(s) enrolls (e.g., self-individual enrolls in the plan or an individual and dependent(s) enrolls (e.g., self-
only coverage, family coverage).only coverage, family coverage).
 Geographic Rating AreaRating Area. Plans may vary premiums based on geographic Plans may vary premiums based on geographic
location. States are required to establish one or more geographic rating areas location. States are required to establish one or more geographic rating areas
within the state for the purposes of this provision. The rating areas must be based within the state for the purposes of this provision. The rating areas must be based
on one of the following geographic boundaries: (1) counties, (2) three-digit zip on one of the following geographic boundaries: (1) counties, (2) three-digit zip
codes, or (3) metropolitan statistical areas (MSAs) and non-MSAs.codes, or (3) metropolitan statistical areas (MSAs) and non-MSAs.33
 Tobacco Use.33 Tobacco Use. Plans may not charge a tobacco user more than 1.5 times the Plans may not charge a tobacco user more than 1.5 times the
premium they charge an individual who does not use tobacco.premium they charge an individual who does not use tobacco.
 Age. Plans may not charge an older individual more than three times the Plans may not charge an older individual more than three times the
premium they charge a 21-year-old individual. All states must use a uniform age premium they charge a 21-year-old individual. All states must use a uniform age
rating curve to specify the rates across age bands (with exceptions for certain rating curve to specify the rates across age bands (with exceptions for certain
states).states).3434 For plan years beginning on or after January 1, 2018, plans must use For plan years beginning on or after January 1, 2018, plans must use
one age band for all individuals aged 0-14 years, one-year age bands for one age band for all individuals aged 0-14 years, one-year age bands for
individuals aged 15-63 years, and one age band for all individuals aged 64 years individuals aged 15-63 years, and one age band for all individuals aged 64 years
and older.and older.
Small-group and Small-group and non-groupnongroup plans are subject to this requirement. plans are subject to this requirement.
Rate Review
Under rate review, proposed annual health insurance rate increases that meet or exceed a federal Under rate review, proposed annual health insurance rate increases that meet or exceed a federal
default threshold are reviewed by a state or the Centers for Medicare & Medicaid Services default threshold are reviewed by a state or the Centers for Medicare & Medicaid Services
(CMS).(CMS).3535 The federal default threshold is 15%. The federal default threshold is 15%.3636 States have the option to apply for state-specific States have the option to apply for state-specific
thresholds.thresholds.37
37 Plans subject to review are required to submit to CMS and the relevant state a justification for the Plans subject to review are required to submit to CMS and the relevant state a justification for the
proposed rate increase prior to its implementation, and CMS and the state must publicly disclose proposed rate increase prior to its implementation, and CMS and the state must publicly disclose
the information. The rate review process does not establish federal authority to deny the information. The rate review process does not establish federal authority to deny
implementation of a proposed rate increase; instead, it is a sunshine provision designed to implementation of a proposed rate increase; instead, it is a sunshine provision designed to
publicly disclose rate increases that are determined to be unreasonable.

33 45 C.F.R. §147.102(b). A three-digit zip code refers to the first three digits of a five-digit zip code. A three-digit zip
code represents a larger geographical area than a five-digit zip code, as all five-digit zip codes that share the same first
three numbers are included in the three-digit zip code.
34 For the federal default and state-specific age rating ratios, see CCIIO, “Market Rating Reforms: State Specific Age
Curve Variations,” at https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Market-Reforms/state-
rating.html#age.
35 42 U.S.C. §300gg-94. CMS identifies whether states have effective rate review systems. In states with effective rate
review systems, the state conducts review; in states that do not have effective rate review systems, CMS conducts the
review.
36 45 C.F.R. §§154.101 and 154.200. The federal default threshold was 10% in previous years. It was modified by
HHS, “HHS Notice of Benefit and Payment Parameters for 2019,” 83 Federal Register 16930, April 17, 2018.
37 Any state that wishes to apply a higher threshold than the federal default must submit a proposal for approval to the
HHS Secretary. Since states generally are allowed to enact stricter requirements compared with relevant federal
provisions, states may impose a rate review threshold that is lower than the federal default on their own without
approval from the Secretary. For more information, see CMS, CCIIO, “State-Specific Threshold Proposals,” at
https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Market-Reforms/sst.html.
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Small-group and non-grouppublicly disclose rate increases that are determined to be unreasonable. Small-group and nongroup plans are subject to this requirement. plans are subject to this requirement.38
38 Single Risk Pool
A risk pool is used to develop premiums for coverage.A risk pool is used to develop premiums for coverage.³⁹ A health insurance issuer must consider all A health insurance issuer must consider all
enrollees in specified plans offered by the issuer to comprise a single risk pool.enrollees in specified plans offered by the issuer to comprise a single risk pool.3940 Specifically, an Specifically, an
issuer must include all enrollees in issuer must include all enrollees in non-groupnongroup plans offered by the issuer in a given state in one plans offered by the issuer in a given state in one
risk pool. Similarly, an issuer must include all enrollees in small-group plans offered by the issuer risk pool. Similarly, an issuer must include all enrollees in small-group plans offered by the issuer
in a given state in a separate risk pool. (However, states have the option to merge their in a given state in a separate risk pool. (However, states have the option to merge their non-group
nongroup and small-group markets; if a state does so, an issuer will have a single risk pool for all enrollees and small-group markets; if a state does so, an issuer will have a single risk pool for all enrollees
in its in its non-groupnongroup and small-group plans.) and small-group plans.)
Small-group and Small-group and non-groupnongroup plans are subject to this requirement. plans are subject to this requirement.
Medical Loss Ratio
A A medical loss ratio (MLR) is the percentage of a plan (MLR) is the percentage of a plan’'s premium revenue spent on medical s premium revenue spent on medical
claims (i.e., plan payments toward enrolleesclaims (i.e., plan payments toward enrollees’' use of health care covered under the plan). use of health care covered under the plan).4041 The The
MLR calculation includes adjustments for quality improvement expenditures, taxes, regulatory MLR calculation includes adjustments for quality improvement expenditures, taxes, regulatory
fees, and other factors. Plans are required to report to the HHS Secretary their MLRs with respect fees, and other factors. Plans are required to report to the HHS Secretary their MLRs with respect
to each plan year. Plans must also meet certain minimum MLR requirements, or otherwise to each plan year. Plans must also meet certain minimum MLR requirements, or otherwise
provide rebates to enrollees.provide rebates to enrollees.
Non-group Nongroup and small-group plans must meet a minimum MLR of 80%; for large groups, the and small-group plans must meet a minimum MLR of 80%; for large groups, the
minimum MLR is 85%. States are permitted to increase the percentages. The HHS Secretary may minimum MLR is 85%. States are permitted to increase the percentages. The HHS Secretary may
lower a statelower a state’'s percentage for the s percentage for the non-groupnongroup market if HHS determines that application of a market if HHS determines that application of a
minimum MLR of 80% would destabilize that stateminimum MLR of 80% would destabilize that state’s non-group market.41's nongroup market.⁴² Plans whose MLR falls Plans whose MLR falls
below the specified limit must provide rebates to enrollees on a pro rata basis. Any required below the specified limit must provide rebates to enrollees on a pro rata basis. Any required
rebates must be paid to enrollees by August of that year.rebates must be paid to enrollees by August of that year.
Large-group, small-group, and Large-group, small-group, and non-groupnongroup plans are subject to this requirement. plans are subject to this requirement.
Covered Benefits
These requirements generally relate to benefits that plans cover (including services such as These requirements generally relate to benefits that plans cover (including services such as
physician visits, and items such as prescription drugs). Some of these provisions include physician visits, and items such as prescription drugs). Some of these provisions include
mandates to cover certain benefits; others do not mandate coverage but impose requirements mandates to cover certain benefits; others do not mandate coverage but impose requirements
related to certain benefits, to the extent they are covered.related to certain benefits, to the extent they are covered.
In addition to the requirements discussed in this section, certain provisions discussed elsewhere in In addition to the requirements discussed in this section, certain provisions discussed elsewhere in
this report also have benefit coverage components (See, e.g., this report also have benefit coverage components (See, e.g., "“Prohibition of Discrimination
Based on Salary.”)

38 45 C.F.R. §§154.101 and 154.200.
39 42 U.S.C. §18032(c) and 45 C.F.R. §156.80.
40 42 U.S.C. §300gg-18.
41 To view a list of state requests for an medical loss ratio adjustment, see CMS, CCIIO, “Ensuring the Affordable Care
Act Serves the American People,” at https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Market-
Reforms/state_mlr_adj_requests.
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Based on Salary.") Coverage of Essential Health Benefits
Plans must cover a core package of Plans must cover a core package of essential health benefits (EHB). (EHB).4243 The benefits that comprise The benefits that comprise
the EHB generally are not defined in federal law; rather, the law lists 10 broad categories in the EHB generally are not defined in federal law; rather, the law lists 10 broad categories in
which benefits must be covered and tasks the HHS Secretary with further defining the EHB.which benefits must be covered and tasks the HHS Secretary with further defining the EHB.43 To
44 The Secretary's definition of EHB must at least include the 10 categories and it must conform to certain limitations and considerations (e.g., it must be equal in scope to the benefits provided under a "typical employer plan").⁴⁵ To date, the HHS Secretary has directed each state to select an EHB benchmark plan, within certain date, the HHS Secretary has directed each state to select an EHB benchmark plan, within certain
parameters, to serve as the basis for the stateparameters, to serve as the basis for the state’'s EHB.s EHB.4446 The benchmark plan serves as a reference The benchmark plan serves as a reference
for applicable plans in that state, which must provide EHB coverage that is for applicable plans in that state, which must provide EHB coverage that is “"substantially equalsubstantially equal”
" to such coverage in the benchmark plan, as specified in regulations.to such coverage in the benchmark plan, as specified in regulations.45
47 Federal regulations have provided specific requirements regarding some EHB categories.Federal regulations have provided specific requirements regarding some EHB categories.4648 For For
example, current regulation provides that an applicable health plan meets the EHB requirements example, current regulation provides that an applicable health plan meets the EHB requirements
for the prescription drugs category of EHB if it covers at least one drug in every U.S. for the prescription drugs category of EHB if it covers at least one drug in every U.S.
Pharmacopeia category and class or the same number of prescription drugs in each category and Pharmacopeia category and class or the same number of prescription drugs in each category and
class as the state-selected EHB benchmark plan.class as the state-selected EHB benchmark plan.
Cost sharing is possible for most categories of EHB, although certain federal requirements limit Cost sharing is possible for most categories of EHB, although certain federal requirements limit
cost sharing on the EHB, as discussed in cost sharing on the EHB, as discussed in “"Enrollee Cost-Sharing and Plan Payment for Benefits.Enrollee Cost-Sharing and Plan Payment for Benefits.”
" Coverage and cost sharing for EHB services furnished by out-of-network providers may vary.Coverage and cost sharing for EHB services furnished by out-of-network providers may vary.
Small-group and Small-group and non-groupnongroup plans are subject to this requirement. plans are subject to this requirement.
Coverage of Preventive Health Services Without Cost Sharing
Plans are required to cover certain preventive health services (and items) without cost sharing. Plans are required to cover certain preventive health services (and items) without cost sharing.
This requirement includes, at a minimum, four categories of statutorily required coverage:This requirement includes, at a minimum, four categories of statutorily required coverage:47
 Preventive49 Evidence-based items or services recommended with an A or B rating by the U.S. Preventive services recommended with an A or B rating by the U.S. Preventive
Services Task Force (USPSTF)Services Task Force (USPSTF)
 Immunizations recommended;⁵⁰ Immunizations that have in effect a recommendation by the Advisory Committee on Immunization by the Advisory Committee on Immunization
Practices (ACIP)
 Additional preventive care and screenings for infants, children, and adolescents,
as recommended by the Health Resources and Services Administration (HRSA)

42 42 U.S.C. §300gg-6; 42 U.S.C. §18022.
43 The 10 categories of essential health benefits (EHB) are ambulatory patient services; emergency services;
hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral
health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive
and wellness services and chronic disease management; and pediatric services, including oral and vision care.
44 For more information on the process for defining the EHB in each state, as well as each state’s benchmark plan, see
CMS, CCIIO, “Information on Essential Health Benefits (EHB) Benchmark Plans,” at https://www.cms.gov/cciio/
resources/data-resources/ehb.
45 45 C.F.R. §156.115(a)(1).
46 See, for example, 45 C.F.R. §156.115 and 45 C.F.R. §156.122.
47 42 U.S.C. §300gg-13; 45 C.F.R. §147.130. The complete list of preventive services required to be covered, per all of
the categories of recommendations, is available at HealthCare.gov, “Preventive Health Services,” at
http://www.healthcare.gov/coverage/preventive-care-benefits/. The four categories of recommendations, as referenced
above, are at U.S. Preventive Services Task Force, “A&B Recommendations,” at
https://uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations; Centers for
Disease Control and Prevention, “ACIP Vaccine Recommendations and Guidelines,” at https://www.cdc.gov/vaccines/
hcp/acip-recs/index.html; Health Resources & Services Administration (HRSA), “Bright Futures,” at
https://mchb.hrsa.gov/programs-impact/bright-futures; and Women’s Preventive Services Initiative,
“Recommendations,” at https://www.womenspreventivehealth.org/recommendations/.
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 Practices (ACIP) of the Centers for Disease Control and Prevention (CDC), for a given individual;⁵¹

Evidence-informed preventive care and screenings for infants, children, and adolescents, as recommended in guidelines supported by the Health Resources and Services Administration (HRSA);⁵² and

Additional preventive care and screenings for women as recommended Additional preventive care and screenings for women as recommended by
HRSA48
in guidelines supported by HRSA.⁵³ If there are changes in recommendations or guidelines in any of these categories (e.g., the If there are changes in recommendations or guidelines in any of these categories (e.g., the
USPSTF announces a new A or B rating), plans generally are required to provide relevant USPSTF announces a new A or B rating), plans generally are required to provide relevant
coverage as of plan years that begin on or after the date that is one year after the change.coverage as of plan years that begin on or after the date that is one year after the change.49
54 Although cost sharing generally is prohibited for specified preventive benefits, cost sharing for Although cost sharing generally is prohibited for specified preventive benefits, cost sharing for
office visits associated with a furnished preventive benefit may be allowed, as specified in office visits associated with a furnished preventive benefit may be allowed, as specified in
regulation.regulation.5055 By regulation, plans generally are not required to cover preventive benefits without By regulation, plans generally are not required to cover preventive benefits without
cost sharing if the benefits are furnished out of network.cost sharing if the benefits are furnished out of network.5156 Additionally, if a recommended Additionally, if a recommended
preventive service does not specify the frequency, method, treatment, or setting for the service, preventive service does not specify the frequency, method, treatment, or setting for the service,
then the plan can determine coverage limitations by relying on then the plan can determine coverage limitations by relying on “"reasonable medical managementreasonable medical management”
techniques.52
" techniques.⁵⁷ Large-group, small-group, self-insured, and Large-group, small-group, self-insured, and non-groupnongroup plans are subject to this requirement. plans are subject to this requirement.
Coverage of COVID-19 Vaccinations and Other Qualifying Preventive Services
Plans are required to cover Coronavirus Disease 2019 (COVID-19) vaccinations (if not otherwise Plans are required to cover Coronavirus Disease 2019 (COVID-19) vaccinations (if not otherwise
covered by the federal government) and vaccine administration fees (even if the vaccines are covered by the federal government) and vaccine administration fees (even if the vaccines are
federally covered) without consumer cost sharing. This requirement also applies to any federally covered) without consumer cost sharing. This requirement also applies to any
“"qualifying coronavirus preventive service,qualifying coronavirus preventive service,”" defined as defined as “"an item, service, or immunization that is an item, service, or immunization that is
intended to prevent or mitigate coronavirus disease 2019intended to prevent or mitigate coronavirus disease 2019”" and that is recommended by the and that is recommended by the
USPSTF or ACIP, as specified.USPSTF or ACIP, as specified.5358 This requirement largely mirrors the existing requirement to This requirement largely mirrors the existing requirement to
cover preventive services without cost sharing, described above. One difference is that this cover preventive services without cost sharing, described above. One difference is that this
coverage requirement is effective 15 business days after a relevant USPSTF or ACIP coverage requirement is effective 15 business days after a relevant USPSTF or ACIP
recommendation.recommendation.54
59 Large-group, small-group, self-insured, and Large-group, small-group, self-insured, and non-groupnongroup plans are subject to this requirement. Coverage for Individuals Participating in Approved Clinical Trials

Plans are subject to nondiscrimination and other provisions with respect to qualified individuals' access to and costs associated with clinical trials.⁶⁰ Specifically, plans cannot

prohibit qualified individuals from participating in an approved clinical trial;

plans are subject to this requirement.

48 For additional information about these categories of recommendations, see the “Federal Regulation of Private Health
Insurance” section of CRS Report R46785, Federal Support for Reproductive Health Services: Frequently Asked
Questions. That and subsequent sections of the report include general discussion of the preventive services coverage
requirement and particular aspects of the requirement (such as coverage of contraceptive services and supplies, per
HRSA recommendations on preventive services for women).
49 See 45 C.F.R. §147.130(b).
50 Whether cost sharing for office visits is allowed generally depends on whether the preventive service or item is the
primary purpose of the visit and whether the service or item is billed or tracked separately from the office visit. See 45
C.F.R. §147.130(a)(2).
51 45 C.F.R. §147.130(a)(3).
52 45 C.F.R. §147.130(a)(4).
53 42 U.S.C. §300gg-13, Statutory Note, “Rapid Coverage of Preventive Services and Vaccines for Coronavirus.”
54 For additional discussion of this requirement, see CRS Report R46359, COVID-19 and Private Health Insurance
Coverage: Frequently Asked Questions. As that report also discusses, the Coronavirus Disease 2019 (COVID-19)
vaccination coverage requirement is not time-limited, but a separate requirement regarding private health insurance
coverage of COVID-19 testing is limited to the duration of the declared public health emergency. For that reason, the
testing coverage requirement is not otherwise included in this report. There are no federal requirements specific to
private health insurance coverage of COVID-19 treatments, but other requirements may be applicable (e.g., coverage of
the EHB).
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Coverage for Individuals Participating in Approved Clinical Trials
Plans are subject to nondiscrimination and other provisions with respect to qualified individuals’
access to and costs associated with clinical trials.55 Specifically, plans cannot
 prohibit qualified individuals from participating in an approved clinical trial;
 deny, limit, or place conditions on the coverage of routine patient costs
deny, limit, or place conditions on the coverage of routine patient costs associated with participation in an approved clinical trial; andassociated with participation in an approved clinical trial; and
 discriminate against qualified individuals on the basis of their participation in discriminate against qualified individuals on the basis of their participation in
approved clinical trials.approved clinical trials.56
61 In short, for a qualified individual participating in an approved clinical trial, a plan must provide In short, for a qualified individual participating in an approved clinical trial, a plan must provide
coverage for routine patient costs (all items and services that typically would be covered under coverage for routine patient costs (all items and services that typically would be covered under
the plan for a qualified individual not enrolled in a clinical trial). Plans may impose consumer the plan for a qualified individual not enrolled in a clinical trial). Plans may impose consumer
cost-sharing requirements on this coverage. Coverage and cost sharing may vary for clinical trials cost-sharing requirements on this coverage. Coverage and cost sharing may vary for clinical trials
offered through an out-of-network provider. The costs of the trialoffered through an out-of-network provider. The costs of the trial’s “'s "investigational item, device, investigational item, device,
or service itselfor service itself”" and other specified costs are not required to be covered by the plan. and other specified costs are not required to be covered by the plan.
Large-group, small-group, self-insured, and Large-group, small-group, self-insured, and non-groupnongroup plans are subject to this requirement. plans are subject to this requirement.
Coverage of Minimum Hospital Stay After Childbirth
Plans that provide coverage for maternity-related hospital stays generally are prohibited from Plans that provide coverage for maternity-related hospital stays generally are prohibited from
restricting coverage for the length of a hospital stay for childbirth for either the mother or the restricting coverage for the length of a hospital stay for childbirth for either the mother or the
newborn child to less than 48 hours newborn child to less than 48 hours forfollowing vaginal deliveries and to less than 96 hours vaginal deliveries and to less than 96 hours forfollowing caesarian caesarian
deliveries.deliveries.5762 In addition, prior authorization requirements for these stays are prohibited. In addition, prior authorization requirements for these stays are prohibited.5863 Cost Cost
sharing is allowed for maternity-related hospital stays, as long as the cost sharing for the portions sharing is allowed for maternity-related hospital stays, as long as the cost sharing for the portions
of hospital stays following deliveries is not greater than cost sharing for preceding portions of of hospital stays following deliveries is not greater than cost sharing for preceding portions of
such stays.such stays.
Large-group, small-group, self-insured, and Large-group, small-group, self-insured, and non-groupnongroup plans are subject to this requirement. plans are subject to this requirement.
Mental Health Parity
Federal parity law does not require plans to cover mental health and substance use disorder Federal parity law does not require plans to cover mental health and substance use disorder
(MH/SUD) benefits when such coverage is not otherwise required by federal or state law. (MH/SUD) benefits when such coverage is not otherwise required by federal or state law.
However, when a plan does cover both MH/SUD benefits and medical/surgical (M/S) benefits, However, when a plan does cover both MH/SUD benefits and medical/surgical (M/S) benefits,
parity law generally prohibits the imposition of more restrictive limitations on the MH/SUD as parity law generally prohibits the imposition of more restrictive limitations on the MH/SUD as
compared with the M/S benefits.59

55 For purposes of this provision, a qualified individual is an individual who (1) is eligible to participate in an approved
clinical trial for treatment of cancer or other life-threatening disease or condition and (2) has a referring health care
provider who either has concluded that the individual’s participation is appropriate or provides medical and scientific
information establishing that participation in a clinical trial would be appropriate.
56 42 U.S.C. §300gg-8.
57 42 U.S.C. §300gg–25. There is an exception to the length-of-coverage requirement when providers make earlier
discharge decisions in consultation with mothers. Plans are prohibited from offering incentives or penalties to providers
or mothers to encourage shorter stays.
58 Some insurers include prior authorization requirements for certain covered benefits. For example, they may require
enrollees to obtain prior authorization from the insurer for routine hospital inpatient care, as a condition for covering
the care.
59 42 U.S.C. §300gg–26. For more information on parity requirements, see CRS Report R47402, Mental Health Parity
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compared with the M/S benefits.⁶⁴ Specifically, plans are prohibited from imposing more restrictive limits on MH/SUD benefits in Specifically, plans are prohibited from imposing more restrictive limits on MH/SUD benefits in
each of the following areas: aggregate lifetime limits and annual limits; financial requirements each of the following areas: aggregate lifetime limits and annual limits; financial requirements
(e.g., co-payments); quantitative treatment limitations (e.g., number of days or visits covered); (e.g., co-payments); quantitative treatment limitations (e.g., number of days or visits covered);
and nonquantitative treatment limitations, or NQTLs (e.g., preauthorization requirements). and nonquantitative treatment limitations, or NQTLs (e.g., preauthorization requirements).
Regulations also have established six classifications of benefits in which parity requirements Regulations also have established six classifications of benefits in which parity requirements
apply: (1) in-network inpatient, (2) out-of-network inpatient, (3) in-network outpatient, (4) out-of-apply: (1) in-network inpatient, (2) out-of-network inpatient, (3) in-network outpatient, (4) out-of-
network outpatient, (5) emergency care, and (6) prescription drugs.network outpatient, (5) emergency care, and (6) prescription drugs.60
65 In addition, plans are required to disclose certain information to enrollees and others upon In addition, plans are required to disclose certain information to enrollees and others upon
request, including the request, including the “"criteria for medical necessity determinationscriteria for medical necessity determinations”" made with respect to made with respect to
MH/SUD benefits.MH/SUD benefits.61
66 Finally, plans are required to Finally, plans are required to annually conduct conduct “"comparative analyses of the design and comparative analyses of the design and
application”application" of their NQTLs and to make these analyses available to applicable federal and state of their NQTLs and to make these analyses available to applicable federal and state
authorities upon request.authorities upon request.6267 The Secretaries of HHS, Labor, and the Treasury must annually The Secretaries of HHS, Labor, and the Treasury must annually
request and review at least 20 of these analyses and follow up on any parity violations identified.request and review at least 20 of these analyses and follow up on any parity violations identified.
Parity requirements apply to large-group plans, self-insured plans offered by large employers, and Parity requirements apply to large-group plans, self-insured plans offered by large employers, and
non-groupnongroup plans. Primarily by incorporation of parity requirements into EHB requirements, plans. Primarily by incorporation of parity requirements into EHB requirements,
small-group plans also are subject to parity law. Self-insured plans offered by small employers are small-group plans also are subject to parity law. Self-insured plans offered by small employers are
exempt, and there is also an exemption for plans facing certain increased costs due to parity exempt, and there is also an exemption for plans facing certain increased costs due to parity
implementation.implementation.63
68 Coverage of Reconstruction After Mastectomy
Plans that provide coverage for mastectomies also must cover prosthetic devices and Plans that provide coverage for mastectomies also must cover prosthetic devices and
reconstructive surgery.reconstructive surgery.6469 Federal guidance has provided that this coverage requirement is Federal guidance has provided that this coverage requirement is
applicable to female and male enrollees, and the mastectomy does not need to have been applicable to female and male enrollees, and the mastectomy does not need to have been
connected to a cancer diagnosis.connected to a cancer diagnosis.6570 Cost sharing is allowed if consistent with cost sharing for other Cost sharing is allowed if consistent with cost sharing for other
covered medical/surgical benefits.covered medical/surgical benefits.
Large-group, small-group, self-insured, and Large-group, small-group, self-insured, and non-groupnongroup plans are subject to this requirement. Coverage of Pregnancy-Related Conditions Certain employers offering health insurance are required to cover " plans are subject to this requirement.

and Coverage in Private Health Insurance: Federal Requirements.
60 45 C.F.R. §146.136.
61 42 U.S.C. §300gg–26(a)(4).
62 42 U.S.C. §300gg–26(a)(8).
63 Although the small employer exemption initially applied to both fully insured and self-insured plans, EHB and parity
regulations have provided that plans subject to EHB requirements (including fully insured plans offered by small
employers) are also subject to parity requirements. Small employers (defined for this purpose as those with 50 or fewer
employees) that self-insure are still exempt from parity requirements. For discussion of these details and the separate
exemption regarding increased costs, see the Department of the Treasury, Department of Labor (DOL), and HHS,
“Final Rules Under the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008;
Technical Amendment to External Review for Multi-State Plan Program,” 78 Federal Register 68239, November 13,
2013, starting at page 68248.
64 42 U.S.C. §300gg–27.
65 See Employee Benefits Security Administration, “Compliance Assistance Guide: Health Benefits Coverage Under
Federal Law.” September 2014, at https://www.dol.gov/sites/dolgov/files/ebsa/about-ebsa/our-activities/resource-
center/publications/compliance-assistance-guide.pdf. Also see DOL, HHS, and Department of the Treasury, “FAQs
About Affordable Care Act Implementation Part 31, Mental Health Parity Implementation, And Women’s Health And
Cancer Rights Act Implementation,” April 20, 2016, at https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/
Downloads/FAQs-31_Final-4-20-16.pdf.
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Coverage of Pregnancy-Related Conditions
Certain employers offering health insurance are required to cover “expenses for pregnancy-expenses for pregnancy-
related conditions on the same basis as expenses for other medical conditionsrelated conditions on the same basis as expenses for other medical conditions”" for employees for employees
enrolled in group plans.enrolled in group plans.6671 If the group plan offers coverage to employees If the group plan offers coverage to employees’' spouses and spouses and
dependents, the requirement to cover pregnancy-related services also applies to employeesdependents, the requirement to cover pregnancy-related services also applies to employees’
' spouses (but not necessarily to other dependents) enrolled in the plan.spouses (but not necessarily to other dependents) enrolled in the plan.
This requirement applies to employers with 15 or more employees, whether their plans are fully This requirement applies to employers with 15 or more employees, whether their plans are fully
insured or self-insured.insured or self-insured.
Prohibition on Coverage Exclusions Based on Preexisting Health Conditions
Plans are prohibited from excluding coverage based on an enrolleePlans are prohibited from excluding coverage based on an enrollee’'s s preexisting health
conditions..6772 This requirement does not mandate coverage for any specific benefit, if a plan This requirement does not mandate coverage for any specific benefit, if a plan
otherwise would not cover it. Rather, with respect to the benefits a plan does cover, the plan may otherwise would not cover it. Rather, with respect to the benefits a plan does cover, the plan may
not exclude coverage of those benefits based on health conditions for any enrollee.not exclude coverage of those benefits based on health conditions for any enrollee.6873 A preexisting A preexisting
health condition is a medical condition that was present before the date of enrollment for health health condition is a medical condition that was present before the date of enrollment for health
coverage, whether or not any medical advice, diagnosis, care, or treatment was recommended or coverage, whether or not any medical advice, diagnosis, care, or treatment was recommended or
received before such date.received before such date.
Large-group, small-group, self-insured, and Large-group, small-group, self-insured, and non-groupnongroup plans are subject to this requirement. plans are subject to this requirement.
Enrollee Cost Sharing and Plan Payment for Benefits
As enrollees receive benefits covered by a plan, the costs for those benefits are paid by the As enrollees receive benefits covered by a plan, the costs for those benefits are paid by the
enrollee and/or by the plan, depending on the planenrollee and/or by the plan, depending on the plan’'s terms. In addition to setting premiums and s terms. In addition to setting premiums and
determining covered benefits, plans set enrolleesdetermining covered benefits, plans set enrollees’' cost-sharing levels. Enrollee cost-sharing levels. Enrollee cost sharing, also , also
called called out-of-pocket (OOP) costs, generally includes deductibles, coinsurance, and co-payments, , generally includes deductibles, coinsurance, and co-payments,
up to annual OOP limits.up to annual OOP limits.6974 The terms of the plan also specify the amounts the plan will pay The terms of the plan also specify the amounts the plan will pay
providers for covered benefits.providers for covered benefits.
The following requirements relate to enrollee cost sharing and/or the costs of the benefits that the The following requirements relate to enrollee cost sharing and/or the costs of the benefits that the
plans cover. They all reference the plans cover. They all reference the "“Coverage of Essential Health Benefits”" requirement requirement
discussed in the prior section. Certain provisions discussed elsewhere in this report are also discussed in the prior section. Certain provisions discussed elsewhere in this report are also
relevant to other aspects of cost sharing or plan payments to providers, such as those relating to relevant to other aspects of cost sharing or plan payments to providers, such as those relating to
out-of-network providers in out-of-network providers in "“Health Care Provider Interactions.”

66 42 U.S.C. §2000e; 29 C.F.R. §1604.10, and 29 C.F.R. §1604, Appendix to Part 1604—Questions and Answers on
the Pregnancy Discrimination Act, P.L. 95-555, 92 Stat. 2076 (1978). See CRS Report R46785, Federal Support for
Reproductive Health Services: Frequently Asked Questions for additional information and citations.
67 42 U.S.C. §300gg-3.
68 Prior to the ACA, some plans were allowed to exclude benefits for preexisting conditions during what was referred to
as an exclusion period. This is different from a waiting period (see the “Waiting Period Limitation” section of this
report).
69 In general, beginning with each plan year, an enrollee pays 100% of costs for covered health care benefits until the
costs meet a certain threshold amount, called a deductible. Exceptions apply. After reaching the deductible , the
enrollee pays coinsurance (a percentage amount) or co-payments (a flat amount) for covered benefits and the plan pays
the rest. If an enrollee’s spending meets an annual out-of-pocket limit, the plan generally will pay 100% of covered
costs for the remainder of the plan year.
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Health Care Provider Interactions." Maximum Annual Limitation on Cost Sharing
Plans must have annual limits on enrollee OOP costs that are no higher than federally set Plans must have annual limits on enrollee OOP costs that are no higher than federally set
amounts.amounts.7075 In other words, once an enrollee In other words, once an enrollee’'s OOP spending has met the federal annual limit (or a s OOP spending has met the federal annual limit (or a
plan’plan's own annual limit, if lower), the plan generally will pay 100% of covered applicable costs s own annual limit, if lower), the plan generally will pay 100% of covered applicable costs
for the remainder of the plan year.for the remainder of the plan year.
HHS adjusts the limits each year through rulemaking and/or guidance using calculations required HHS adjusts the limits each year through rulemaking and/or guidance using calculations required
by the ACA.by the ACA.71 In 202376 In 2025, the limits cannot exceed $9,, the limits cannot exceed $9,100200 for for self-only coverage and $18, coverage and $18,200400 for for
coverage coverage other than self-only..7277 If a consumer is solely enrolled in a plan, the self-only limit If a consumer is solely enrolled in a plan, the self-only limit
applies. If a consumer and one or more dependents are enrolled in a plan, both types of limits applies. If a consumer and one or more dependents are enrolled in a plan, both types of limits
apply.apply.73
78 The limits generally apply only to in-network coverage of the EHB.The limits generally apply only to in-network coverage of the EHB.7479 However, certain However, certain
exceptions may apply.exceptions may apply.75
80 Large-group, small-group, self-insured, and Large-group, small-group, self-insured, and non-groupnongroup plans are subject to this requirement. plans are subject to this requirement.76
81 Minimum Actuarial Value Requirements
Plans must pay for covered benefits in compliance with minimum actuarial value (AV) standards. Plans must pay for covered benefits in compliance with minimum actuarial value (AV) standards.
AV estimates the AV estimates the “"percentage of total average costs for covered benefitspercentage of total average costs for covered benefits”" to be paid by a plan. to be paid by a plan.77 A
plan’82 A plan's AV must comply with one of four levels corresponding with a precious metal designation (i.e., platinum, gold, silver, or bronze).⁸³s AV must comply with one of four levels corresponding with a precious metal designation

70 42 U.S.C. §300gg-6; 42 U.S.C. §18022.
71 See, for example, CMS, CCIIO, “Premium Adjustment Percentage, Maximum Annual Limitation on Cost Sharing,
Reduced Maximum Annual Limitation on Cost Sharing, and Required Contribution Percentage for the 2023 Benefit
Year,” December 28, 2021, at https://www.cms.gov/files/document/2023-papi-parameters-guidance-v4-final-12-27-21-
508.pdf.
72 See CRS Report R44065, Overview of Health Insurance Exchanges, Table 2, for these and prior year annual limits.
73 For example, for a family of three enrolled in a plan with the 2023 limits: Once individual 1 incurs $9,100 in cost
sharing for his or her benefits as specified above (generally, on in-network EHB), the plan is responsible for 100% of
the costs for such benefits for the rest of the plan year. However, if individuals 2 and 3 have incurred only $2,000 each
in cost sharing, they would still be responsible for cost sharing at that time. If any of the enrollees’ cost sharing adds up
to $18,200, then the plan would be responsible for 100% of all of the enrollees’ costs for covered benefits for the rest of
the plan year. For additional information about the annual OOP limit, see CMS, CCIIO, “Embedded Self-Only Annual
Limitation on Cost Sharing FAQs,” May 8, 2015, at https://www.dol.gov/sites/default/files/ebsa/laws-and-regulations/
laws/affordable-care-act/for-employers-and-advisers/hhs-guidance-embedded-self-only-annual-limitation-on-cost-
sharing-faqs.pdf.
7445 C.F.R. §156.130. Also see HHS, DOL, and Treasury, “Affordable Care Act Implementation FAQs – Set 18,”
January 9, 2014, at https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/aca_implementation_faqs18,
including questions 2 and 4. Hereinafter referred to as Tri-Agency FAQ 18.
75 See, for example, “Preventing Surprise Medical and Air Ambulance Bills.” Also see 45 C.F.R. §156.130(h)
regarding prescription drug coupons.
76 This requirement applies to EHB coverage, and large-group and self-insured plans are not required to cover the EHB.
The Tri-Agency FAQ 18, question 2, provides that such plans must use a permissible definition of EHB (including any
state-selected EHB benchmark plan) to determine whether they comply with this requirement. This is consistent with
regulations implementing the separate “Prohibition on Lifetime and Annual Coverage Limits”.
77 See the definition of actuarial value in the glossary on HealthCare.gov at https://www.healthcare.gov/glossary/
actuarial-value/.
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(i.e., platinum, gold, silver, or bronze).78 The four AV levels are 90% for platinum, 80% for gold, The four AV levels are 90% for platinum, 80% for gold,
70% for silver, and 60% for bronze.70% for silver, and 60% for bronze.79
84 Given that plans and enrollees collectively pay total costs, AV is the plan counterpart to enrollee Given that plans and enrollees collectively pay total costs, AV is the plan counterpart to enrollee
cost-sharing expenses. The higher the AV percentage, the lower the cost sharing, on average. For cost-sharing expenses. The higher the AV percentage, the lower the cost sharing, on average. For
example, a silver plan expects to cover approximately 70% of total costs for covered benefits. example, a silver plan expects to cover approximately 70% of total costs for covered benefits.
Because enrolleesBecause enrollees’' use of such benefits vary, a given enrollee use of such benefits vary, a given enrollee’'s actual cost sharing may be more s actual cost sharing may be more
or less than 30% of costs associated with receipt of covered benefits. AV is not a measure of plan or less than 30% of costs associated with receipt of covered benefits. AV is not a measure of plan
generosity for an enrolled individual or family, nor is it a measure of premiums or benefits generosity for an enrolled individual or family, nor is it a measure of premiums or benefits
packages.packages.
AV calculations include only costs associated with a planAV calculations include only costs associated with a plan’'s covered EHB that are furnished by in-s covered EHB that are furnished by in-
network providers, unless otherwise addressed in federal or state law.network providers, unless otherwise addressed in federal or state law.80
85 Small-group and Small-group and non-groupnongroup plans are subject to this requirement. plans are subject to this requirement.
Prohibition on Lifetime and Annual Coverage Limits
Plans are prohibited from setting lifetime or annual dollar limits on their coverage of the EHB, Plans are prohibited from setting lifetime or annual dollar limits on their coverage of the EHB,
generally whether provided in-network or out-of-network.generally whether provided in-network or out-of-network.8186 In other words, plans may not limit In other words, plans may not limit
their spending for such benefits for any enrollee, either during the entire period an individual is their spending for such benefits for any enrollee, either during the entire period an individual is
enrolled in the plan (enrolled in the plan (lifetime coverage limits) or during a plan year () or during a plan year (annual coverage limits).).
Plans are permitted to place lifetime and annual coverage limits on covered benefits that are not Plans are permitted to place lifetime and annual coverage limits on covered benefits that are not
considered EHBs, to the extent that federal and state law otherwise permit such limits.considered EHBs, to the extent that federal and state law otherwise permit such limits.
Large-group, small-group, self-insured, and Large-group, small-group, self-insured, and non-groupnongroup plans are subject to this requirement. plans are subject to this requirement.82
87 Health Care Provider Interactions
These requirements relate to plan interactions and consumer interactions with providers, These requirements relate to plan interactions and consumer interactions with providers,
including in the context of plan coverage and benefits for services furnished to enrollees by including in the context of plan coverage and benefits for services furnished to enrollees by
certain out-of-network providers.certain out-of-network providers.
Certain requirements discussed in this section relate to provisions discussed elsewhere in this Certain requirements discussed in this section relate to provisions discussed elsewhere in this
report. (See, e.g., the relationship between report. (See, e.g., the relationship between "“Provider Directory Requirements” and “" and "Services
Provided Based on Incorrect Provider Directory Information.”)
.") Preventing Surprise Medical and Air Ambulance Bills
Plans are required to limit consumer cost sharing and to pay providers a specified amount when Plans are required to limit consumer cost sharing and to pay providers a specified amount when
enrollees receive certain out-of-network medical care:83

78 42 U.S.C. §300gg-6; 42 U.S.C. §18022.
79 Regulations allow plans to fall within a specified actuarial value range and still comply with one of the four levels;
see 45 C.F.R. §156.140(c)(2).
80 45 C.F.R. §§156.20 and 156.135.
81 42 U.S.C. §300gg-11; 45 C.F.R. §147.126.
82 This requirement applies to EHB coverage, and large-group and self-insured plans are not required to cover the EHB.
Regulations provide that such plans must use a permissible definition of EHB (including any state-selected EHB
benchmark plan) to determine whether they comply with this requirement. See 45 C.F.R. §147.126(c).
83 42 U.S.C. §§300gg-111 and 300gg-112. For more information on the topic of surprise billing, including these federal
requirements, see CRS Report R46856, Surprise Billing in Private Health Insurance: Overview of Federal Consumer
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 enrollees receive certain out-of-network medical care:⁸⁸ Out-of-network emergency services (if the plan covers services in an emergency Out-of-network emergency services (if the plan covers services in an emergency
department of a hospital or an independent freestanding emergency department)department of a hospital or an independent freestanding emergency department)
 Nonemergency services provided by an out-of-network provider at an in-network Nonemergency services provided by an out-of-network provider at an in-network
facility (when notice and consent requirements have not been satisfied)facility (when notice and consent requirements have not been satisfied)84
 89 Out-of-network air ambulance servicesOut-of-network air ambulance services
When applicable, the cost-sharing requirement for these services cannot be greater than the cost When applicable, the cost-sharing requirement for these services cannot be greater than the cost
sharing that would have applied for the service had it been provided by an in-network provider.sharing that would have applied for the service had it been provided by an in-network provider.85
90 Generally, plans are required to calculate cost-sharing amounts based on the lesser of the billed Generally, plans are required to calculate cost-sharing amounts based on the lesser of the billed
charge for the service or the plancharge for the service or the plan’'s median in-network rate for the service.s median in-network rate for the service.8691 Any cost-sharing Any cost-sharing
amounts paid by enrollees must be counted toward any in-network deductibles and in-network amounts paid by enrollees must be counted toward any in-network deductibles and in-network
OOP maximums.OOP maximums.
The amount a plan is required to pay a provider for these out-of-network services is determined The amount a plan is required to pay a provider for these out-of-network services is determined
according to a federal payment methodology.according to a federal payment methodology.8792 Under this methodology, the plan must make an Under this methodology, the plan must make an
initial payment (or notice of denial of payment) to the out-of-network provider for services initial payment (or notice of denial of payment) to the out-of-network provider for services
rendered, after which the parties may negotiate to reach an agreed-upon payment amount. If rendered, after which the parties may negotiate to reach an agreed-upon payment amount. If
negotiations are unsuccessful, the parties may use an independent dispute resolution process, negotiations are unsuccessful, the parties may use an independent dispute resolution process,
wherein an arbitrator determines the final payment amount. However, if a state has its own wherein an arbitrator determines the final payment amount. However, if a state has its own
surprise billing law that pertains to a given plan type, provider type, and service, the state law surprise billing law that pertains to a given plan type, provider type, and service, the state law
methodology would apply. In addition, if a state has an all-payer model agreement, the amount methodology would apply. In addition, if a state has an all-payer model agreement, the amount
designated under the agreement would apply.designated under the agreement would apply.
In addition to the requirements above regarding out-of-network emergency benefits, plans must In addition to the requirements above regarding out-of-network emergency benefits, plans must
comply with additional requirements relating to benefits for emergency services.comply with additional requirements relating to benefits for emergency services.8893 If a plan If a plan
covers services in an emergency department of a hospital or emergency services in an covers services in an emergency department of a hospital or emergency services in an
independent freestanding emergency department, the plan is required to cover those services independent freestanding emergency department, the plan is required to cover those services
without the need for any prior authorization, without coverage limitations or requirements for out-without the need for any prior authorization, without coverage limitations or requirements for out-
of-network providers and facilities that are more restrictive than the limitations or requirements of-network providers and facilities that are more restrictive than the limitations or requirements
that apply to in-network emergency providers and facilities, and regardless of any other term or that apply to in-network emergency providers and facilities, and regardless of any other term or
condition of the plan (with limited exceptions).condition of the plan (with limited exceptions).
Large-group, small-group, self-insured, and Large-group, small-group, self-insured, and non-groupnongroup plans are subject to this requirement. plans are subject to this requirement.
Continuity of Care
Plans are required to satisfy certain requirements when Plans are required to satisfy certain requirements when continuing care patients receive services receive services
from a provider that initially was in network but subsequently became out of network during the

Protections and Payment for Out-of-Network Services.
84 For notice and consent requirements, see 42 U.S.C. §300gg-132(d).
85 With covered, out-of-network air ambulance services specifically, the cost-sharing requirement must be the same as
the cost sharing for an in-network provider.
86 For applicable emergency services and covered nonemergency services provided by an out-of-network provider at an
in-network facility, if the service is provided in a state that has an applicable surprise billing law or an all-payer model
agreement, the cost-sharing amount is to be calculated in accordance with such law or agreement. See definition of
recognized amount at 45 C.F.R. 149.30, as referenced by 45 C.F.R 149.110(b)(3)(iii). For air ambulance services, see
45 C.F.R. 149.130(b)(2).
87 For more information on the federal payment methodology, see CRS In Focus IF12073, Surprise Billing:
Independent Dispute Resolution Process.
88 42 U.S.C. §300gg-111(a)(1).
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from a provider that initially was in network but subsequently became out of network during the course of treatment (i.e., as a result of the termination of the contractual relationship between the course of treatment (i.e., as a result of the termination of the contractual relationship between the
plan and provider).plan and provider).8994 In these situations, plans must In these situations, plans must
 notify the continuing care patientnotify the continuing care patient of the termination and the enrolleeof the termination and the enrollee’'s right to s right to
elect continued transitional care from the now-out-of-network provider;elect continued transitional care from the now-out-of-network provider;
 provide the continuing care patientprovide the continuing care patient with an opportunity to notify the plan of his with an opportunity to notify the plan of his
or her need for transitional care; andor her need for transitional care; and
 permit the continuing care patientpermit the continuing care patient to continue his or her course of treatment from to continue his or her course of treatment from
the now out-of-network provider for, at most, 90 days and under the same terms the now out-of-network provider for, at most, 90 days and under the same terms
and conditions as applied when the provider was in network.and conditions as applied when the provider was in network.
Large-group, small-group, self-insured, and Large-group, small-group, self-insured, and non-groupnongroup plans are subject to this requirement. plans are subject to this requirement.
Services Provided Based on Incorrect Provider Directory Information
Plans must limit consumer cost sharing for covered, out-of-network services provided to enrollees Plans must limit consumer cost sharing for covered, out-of-network services provided to enrollees
who relied on incorrect provider network information.who relied on incorrect provider network information.9095 If an enrollee receives a covered service If an enrollee receives a covered service
from an out-of-network provider that the enrollee thought was in network due to incorrect from an out-of-network provider that the enrollee thought was in network due to incorrect
information from the plan, the cost-sharing requirement cannot be greater than the cost sharing information from the plan, the cost-sharing requirement cannot be greater than the cost sharing
that would have applied had the service been provided by an in-network provider. In addition, that would have applied had the service been provided by an in-network provider. In addition,
plans must count any of these out-of-network cost-sharing amounts toward any in-network plans must count any of these out-of-network cost-sharing amounts toward any in-network
deductibles and in-network OOP maximums.deductibles and in-network OOP maximums.
Large-group, small-group, self-insured, and Large-group, small-group, self-insured, and non-groupnongroup plans are subject to this requirement. plans are subject to this requirement.
Choice of HealthcareHealth Care Professionals
Plans are subject to three requirements relating to the choice of health care professionals.Plans are subject to three requirements relating to the choice of health care professionals.9196 First, First,
plans that require or allow an enrollee to designate a participating primary care provider are plans that require or allow an enrollee to designate a participating primary care provider are
required to permit the designation of any participating primary care provider who is available to required to permit the designation of any participating primary care provider who is available to
accept the individual. Second, plans that require or allow an enrollee to designate a participating accept the individual. Second, plans that require or allow an enrollee to designate a participating
primary care provider for an enrolled child are required to permit the designation of a primary care provider for an enrolled child are required to permit the designation of a
participating physician who specializes in pediatrics as the childparticipating physician who specializes in pediatrics as the child’'s primary care provider. Third, s primary care provider. Third,
plans that provide coverage for obstetrical or gynecological care cannot require authorization or plans that provide coverage for obstetrical or gynecological care cannot require authorization or
referral by the plan or any person (including a primary care provider) for a female enrollee who referral by the plan or any person (including a primary care provider) for a female enrollee who
seeks obstetrical or gynecological care from an in-network health care professional who seeks obstetrical or gynecological care from an in-network health care professional who
specializes in obstetrics or gynecology.specializes in obstetrics or gynecology.
Large-group, small-group, self-insured, and Large-group, small-group, self-insured, and non-groupnongroup plans are subject to this requirement. plans are subject to this requirement.
Nondiscrimination Regarding Health Care Providers
Plans may not discriminate, with respect to participation under the plan, against any health care Plans may not discriminate, with respect to participation under the plan, against any health care
provider that is acting within the scope of that providerprovider that is acting within the scope of that provider’'s license or certification under applicable s license or certification under applicable
state law.state law.9297 Federal law does not require that a plan contract with any health care provider willing Federal law does not require that a plan contract with any health care provider willing

89 42 U.S.C. §300gg-113. For purposes of this provision, a continuing care patient is an individual who satisfies one of
the following criteria: (1) is undergoing treatment for a serious and complex condition; (2) is undergoing institutional
or inpatient care; (3) is scheduled to undergo nonelective surgery; (4) is pregnant and undergoing a course of treatment
for the pregnancy; or (5) is or was determined to be terminally ill and is receiving treatment for such illness.
90 42 U.S.C. §300gg-115(b).
91 42 U.S.C. §300gg-117.
92 42 U.S.C. §300gg-5.
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to abide by the plan’to abide by the plan's terms and conditions, and it also does not prevent a plan or the HHS s terms and conditions, and it also does not prevent a plan or the HHS
Secretary from establishing varying reimbursement rates for providers based on quality or Secretary from establishing varying reimbursement rates for providers based on quality or
performance measures.performance measures.
Large-group, small-group, self-insured, and Large-group, small-group, self-insured, and non-groupnongroup plans are subject to this requirement. plans are subject to this requirement.
Prohibition on Gag Clauses on Price and Quality Information
Plans are prohibited from entering into agreements with providers and other selected entities that Plans are prohibited from entering into agreements with providers and other selected entities that
would directly or indirectly prevent the plan fromwould directly or indirectly prevent the plan from
 disclosing provider-specific cost or quality of care information to referring disclosing provider-specific cost or quality of care information to referring
providers, enrollees, plan sponsors, or individuals eligible to enroll in the plan;providers, enrollees, plan sponsors, or individuals eligible to enroll in the plan;
 electronically accessing de-identified claims and encounter data for each electronically accessing de-identified claims and encounter data for each
enrollee;93 and
 enrollee;⁹⁸ and sharing such information with a business associate, consistent with applicable sharing such information with a business associate, consistent with applicable
privacy regulations.privacy regulations.94
99 Plans are required to annually attest to the Departments of HHS, Labor, and the Treasury that the Plans are required to annually attest to the Departments of HHS, Labor, and the Treasury that the
plans are in compliance with this requirement.plans are in compliance with this requirement.
Large-group, small-group, self-insured, and Large-group, small-group, self-insured, and non-groupnongroup plans are subject to this requirement. plans are subject to this requirement.
Enrollee Information and Appeals
Requirements in this section relate to plan disclosure of certain information to enrollees (and Requirements in this section relate to plan disclosure of certain information to enrollees (and
applicants, as specified) and to enrolleesapplicants, as specified) and to enrollees’' rights regarding appeals of coverage denials. rights regarding appeals of coverage denials.
In addition to the requirements discussed below, certain provisions discussed elsewhere in this In addition to the requirements discussed below, certain provisions discussed elsewhere in this
report also have enrollee information and appeals components (see, e.g.report also have enrollee information and appeals components (see, e.g., “, "Mental Health Parity”).
"). Summary of Benefits and Coverage and Uniform Glossary
Plans are required to provide a Plans are required to provide a summary of benefits and coverage (SBC) to individuals at the time (SBC) to individuals at the time
of application, by the first day of coverage (if there are changes since the time of application), of application, by the first day of coverage (if there are changes since the time of application),
prior to the time of renewal, and otherwise upon request.prior to the time of renewal, and otherwise upon request.95 100 The SBC must meet certain The SBC must meet certain
requirements with respect to the included content and the presentation of the content (e.g., it must requirements with respect to the included content and the presentation of the content (e.g., it must
include uniform definitions of health insurance terms and a description of the coverage and cost include uniform definitions of health insurance terms and a description of the coverage and cost
sharing for specified categories of benefits). Plans may provide the SBC in paper or electronic sharing for specified categories of benefits). Plans may provide the SBC in paper or electronic
form. Plans must notify enrollees of any material modifications (e.g., changes in benefits) no later form. Plans must notify enrollees of any material modifications (e.g., changes in benefits) no later
than 60 days prior to the date that the modifications would than 60 days prior to the date that the modifications would become effective.
go into effect. Plans also must provide a uniform glossary of terms commonly used in health insurance coverage Plans also must provide a uniform glossary of terms commonly used in health insurance coverage
(e.g., coinsurance) to enrollees upon request.(e.g., coinsurance) to enrollees upon request.
Large-group, small-group, self-insured, and Large-group, small-group, self-insured, and non-groupnongroup plans are subject to these requirements. Advanced Explanation of Benefits plans are subject to these requirements.

93 This component of the requirement applies to group health plans only.
94 42 U.S.C. §300gg-119. The term business associate is defined at 45 C.F.R. §160.103.
95 42 U.S.C. §300gg-15; 45 C.F.R. §147.200.
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Advanced Explanation of Benefits
When an enrollee schedules to receive medical care from a provider and seeks to have the care When an enrollee schedules to receive medical care from a provider and seeks to have the care
covered by a plan, providers are required to provide a good-faith estimate of expected charges for covered by a plan, providers are required to provide a good-faith estimate of expected charges for
such care to the enrolleesuch care to the enrollee’'s plan.s plan.96101 Upon receipt of this estimate, plans are required to develop a Upon receipt of this estimate, plans are required to develop a
notification, referred to as an notification, referred to as an advance explanation of benefits, and provide it to the enrollee , and provide it to the enrollee
within designated timeframes.within designated timeframes.97102 The advance explanation of benefits must contain specified The advance explanation of benefits must contain specified
pieces of information, including the providerpieces of information, including the provider’'s network status, the providers network status, the provider’'s good-faith estimate s good-faith estimate
of expected charges, the planof expected charges, the plan’'s estimated payment toward the expected charges, the enrollees estimated payment toward the expected charges, the enrollee’s
's estimated cost sharing, an estimate of the amounts accumulated toward the enrolleeestimated cost sharing, an estimate of the amounts accumulated toward the enrollee’'s deductible s deductible
and OOP limit, whether the scheduled care is subject to a medical management technique,and OOP limit, whether the scheduled care is subject to a medical management technique,98103 and a and a
disclaimer that the information in the advance explanation of benefits comprises estimates that disclaimer that the information in the advance explanation of benefits comprises estimates that
are subject to change.are subject to change.
Large-group, small-group, self-insured, and Large-group, small-group, self-insured, and non-groupnongroup plans are subject to this requirement. The plans are subject to this requirement. The
Departments of HHS, Labor, and the Treasury have deferred enforcement of this requirement Departments of HHS, Labor, and the Treasury have deferred enforcement of this requirement
until the departments undertake notice and comment rulemaking.until the departments undertake notice and comment rulemaking.99104 As of the date of this report, As of the date of this report,
regulations have not been issued.regulations have not been issued.
Plan Identification Card Information
Plans are required to include the following on any physical or electronic enrollee plan Plans are required to include the following on any physical or electronic enrollee plan
identification cards: any deductible applicable to the plan, any OOP maximum limitation identification cards: any deductible applicable to the plan, any OOP maximum limitation
applicable to the plan, and a consumer assistance telephone number and website.applicable to the plan, and a consumer assistance telephone number and website.100
105 Large-group, small-group, self-insured, and Large-group, small-group, self-insured, and non-groupnongroup plans are subject to this requirement. plans are subject to this requirement.
Price Comparison Tool
Plans are required to disclose certain price comparison information to enrollees through a self-Plans are required to disclose certain price comparison information to enrollees through a self-
service tool on a website; by telephone; and, upon request, in paper.service tool on a website; by telephone; and, upon request, in paper.101106 Price comparison Price comparison
information includes but is not limited to an estimate of the enrolleeinformation includes but is not limited to an estimate of the enrollee’'s cost sharing for covered s cost sharing for covered
items and services items and services furnished by any providerby billing code or descriptive term, amounts accumulated, in-network rates, and out-of-, amounts accumulated, in-network rates, and out-of-
network allowed amounts.network allowed amounts.102107
Large-group, small-group, self-insured, and Large-group, small-group, self-insured, and non-groupnongroup plans are subject to this requirement. Provider Directory Requirements Plans are required to establish and adhere to certain provider directory standards.¹⁰⁸ These plans are subject to this requirement.
Plans must disclose price comparison information for 500 specified items or services for plan
years that begin on or after January 1, 2023. This list expands to all services for plan years that
begin on or after January 1, 2024.103

96 Good-faith cost estimates are required to be provided when care is scheduled at least three business days in advance
(or upon request of the enrollee). 42 U.S.C. §300gg-136.
97 42 U.S.C. §300gg-111(f).
98 The term medical management technique includes concurrent review, prior authorization, and step-therapy or fail-
first protocols. 42 U.S.C. §300gg-111(f)(1)(F).
99 DOL, HHS, and Treasury, “FAQs Part 49.”
100 42 U.S.C. §300gg-111(e).
101 42 U.S.C. §300gg-114, 42 U.S.C. §300gg-15a, and 45 C.F.R. §147.211.
102 45 C.F.R. §147.211.
103 DOL, HHS, and Treasury, “FAQs Part 49.”
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Provider Directory Requirements
Plans are required to establish and adhere to certain provider directory standards.104 These
standards require plans to establish a public, online database that contains provider directory standards require plans to establish a public, online database that contains provider directory
information for each provider with which they have a direct or indirect relationship. The information for each provider with which they have a direct or indirect relationship. The
standards also require plans to establish a process to verify and update this information at least standards also require plans to establish a process to verify and update this information at least
once every 90 days. In addition, they require plans to establish a protocol to respond to enrollees once every 90 days. In addition, they require plans to establish a protocol to respond to enrollees
who request information (via phone or electronically) about a providerwho request information (via phone or electronically) about a provider’'s network status. Federal s network status. Federal
law also requires that print directories include language indicating the date on which the law also requires that print directories include language indicating the date on which the
information was accurate and noting that enrollees should consult the online database or the plan information was accurate and noting that enrollees should consult the online database or the plan
to obtain the most current provider directory information.to obtain the most current provider directory information.
Large-group, small-group, self-insured, and Large-group, small-group, self-insured, and non-groupnongroup plans are subject to this requirement. plans are subject to this requirement.
Disclosure of Patient Protections Against Balance Billing
Plans are required to disclose information on federal surprise billing requirements;Plans are required to disclose information on federal surprise billing requirements;105109 applicable applicable
state requirements addressing out-of-network provider charges, where appropriate; and the state requirements addressing out-of-network provider charges, where appropriate; and the
appropriate state and federal agencies that an individual can contact if a provider is believed to appropriate state and federal agencies that an individual can contact if a provider is believed to
have violated such requirements.have violated such requirements.106110 This information must be made publicly available, posted on This information must be made publicly available, posted on
a public website of the plan, and included on each explanation of benefits for out-of-network a public website of the plan, and included on each explanation of benefits for out-of-network
emergency services and covered, nonemergency services provided by an out-of-network provider emergency services and covered, nonemergency services provided by an out-of-network provider
at an in-network facility.at an in-network facility.
Large-group, small-group, self-insured, and Large-group, small-group, self-insured, and non-groupnongroup plans are subject to this requirement. plans are subject to this requirement.
Information on Prescription Drugs
Plans (including the pharmacy benefit managers contracted with them) are prohibited from Plans (including the pharmacy benefit managers contracted with them) are prohibited from
restricting pharmacies from informing health plan enrollees of the difference in OOP costs they restricting pharmacies from informing health plan enrollees of the difference in OOP costs they
would pay for a prescription drug using their health plan coverage versus going would pay for a prescription drug using their health plan coverage versus going “outside”"outside" of their of their
health plan benefit to purchase a prescription drug.health plan benefit to purchase a prescription drug.107111 Stated another way, this requirement aims Stated another way, this requirement aims
to end what some refer to as gag clauses in contracts between pharmacies and plans or pharmacy

104 42 U.S.C. §300gg-115(a).
105 More specifically, the requirements on plans at 42 U.S.C. §300gg-111 and the requirements on providers prohibiting
balance billing in certain circumstances at 42 U.S.C. §§300gg-131, 132. The term balance billing, which is one type of
surprise bill, refers to amounts that an out-of-network provider can charge a consumer for care that is in addition to the
amount the consumer pays in out-of-network cost sharing and the amounts that the provider receives from a plan for
such services. For more information on the relationship between surprise bills and balance bills, see the “Private Health
Insurance Billing Overview” in CRS Report R46856, Surprise Billing in Private Health Insurance: Overview of
Federal Consumer Protections and Payment for Out-of-Network Services. For a discussion of the surprise billing
requirements at 42 U.S.C. §300gg-111 regarding out-of-network emergency services and covered, nonemergency
services provided by an out-of-network provider at an in-network facility (when notice and consent requirements have
not been satisfied), see “Preventing Surprise Medical and Air Ambulance Bills.”
106 42 U.S.C. §300gg-115(c).
107 42 U.S.C. §300gg-19b. Pharmacy benefit managers (PBMs) are intermediaries between health plans and
pharmacies, drug wholesalers, and manufacturers. PBMs perform functions such as designing drug formularies,
negotiating prices, and administering prescription drug payment systems. For more information, see CRS Report
R44832, Frequently Asked Questions About Prescription Drug Pricing and Policy.
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to end what some refer to as gag clauses in contracts between pharmacies and plans or pharmacy benefit managers and to allow pharmacies to inform health plan enrollees if it would be less benefit managers and to allow pharmacies to inform health plan enrollees if it would be less
expensive for them to obtain their prescription without using their health plan benefit.expensive for them to obtain their prescription without using their health plan benefit.108
112 Large-group, small-group, self-insured, and Large-group, small-group, self-insured, and non-groupnongroup plans are subject to this requirement. plans are subject to this requirement.
Disclosure to Enrollees of Individual Market Coverage
Plans are required to disclose to enrollees any direct or indirect compensation provided to agents Plans are required to disclose to enrollees any direct or indirect compensation provided to agents
or brokers associated with enrolling individuals in such coverage.or brokers associated with enrolling individuals in such coverage.109113 Plans must make this Plans must make this
disclosure prior to an individual finalizing a plan selection and must include the disclosure on any disclosure prior to an individual finalizing a plan selection and must include the disclosure on any
documentation confirming the individualdocumentation confirming the individual’'s enrollment. The plan also must annually report similar s enrollment. The plan also must annually report similar
information to HHS.information to HHS.
Non-group Nongroup plans are subject to this requirement. plans are subject to this requirement.
Appeals Process and External Review
Plans must implement an effective appeals process for coverage determinations and claims.Plans must implement an effective appeals process for coverage determinations and claims.110114 At At
a minimum, plans musta minimum, plans must
 have an internal claims appeals process;have an internal claims appeals process;
 provide notice to enrollees regarding available internal and external appeals provide notice to enrollees regarding available internal and external appeals
processes and the availability of any applicable assistance; andprocesses and the availability of any applicable assistance; and
 allow an enrollee to review his or her file, present evidence and testimony, and allow an enrollee to review his or her file, present evidence and testimony, and
receive continued coverage pending the outcome.receive continued coverage pending the outcome.
Plans also must implement either a state or a federal external review process for coverage Plans also must implement either a state or a federal external review process for coverage
determinations and claims.determinations and claims.111
115 Large-group, small-group, self-insured, and Large-group, small-group, self-insured, and non-groupnongroup plans are subject to this requirement. plans are subject to this requirement.
Federal and Public Reporting Requirements
The following requirements relate to the reporting of specified information to the federal The following requirements relate to the reporting of specified information to the federal
government and/or the public disclosure of certain information.government and/or the public disclosure of certain information.
In addition to the requirements discussed in this section, certain provisions discussed elsewhere in In addition to the requirements discussed in this section, certain provisions discussed elsewhere in
this report also have federal and public reporting requirement components (see, e.g., this report also have federal and public reporting requirement components (see, e.g., "“Mental
Health Parity”).
"). Reporting Requirements Regarding Quality of Care
The HHS Secretary was required to develop quality reporting requirements for use by specified The HHS Secretary was required to develop quality reporting requirements for use by specified
plans, concluding no later than two years after enactment of the ACA.plans, concluding no later than two years after enactment of the ACA.112116 The Secretary also was The Secretary also was

108 For more information on prescription drug coupons and patient assistance programs, see CRS Report R44264,
Prescription Drug Discount Coupons and Patient Assistance Programs (PAPs).
109 42 U.S.C. §300gg-46. Separately, disclosure provisions require those providing “brokerage services” or
“consulting” to group health plans to disclose specified information, including information regarding direct and indirect
compensation, to plan fiduciaries. See 29 U.S.C. §1108(b)(2).
110 42 U.S.C. §300gg-19(a).
111 42 U.S.C. §300gg-19(b).
112 42 U.S.C. §300gg-17.
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required to publish regulations governing acceptable provider reimbursement structures not later required to publish regulations governing acceptable provider reimbursement structures not later
than two years after ACA enactment. No later than 180 days after these regulations were than two years after ACA enactment. No later than 180 days after these regulations were
promulgated, the U.S. Government Accountability Office was required to conduct a study promulgated, the U.S. Government Accountability Office was required to conduct a study
regarding the impact of these activities on the quality and cost of health care. To date, the HHS regarding the impact of these activities on the quality and cost of health care. To date, the HHS
Secretary has not published the required final regulations.Secretary has not published the required final regulations.
However, the Department of LaborHowever, the Department of Labor’'s (DOLs (DOL’'s) Employee Benefits Security Administration s) Employee Benefits Security Administration
published a proposed rule on July 21, 2016, that would modify current annual reporting published a proposed rule on July 21, 2016, that would modify current annual reporting
requirements for pension and other employee benefit plans under ERISA Titles I and IV.requirements for pension and other employee benefit plans under ERISA Titles I and IV.113117 Under Under
these modified requirements, plans would report on the financial condition and operations of the these modified requirements, plans would report on the financial condition and operations of the
plan, among other things, using standardized forms (Form 5500 Annual Return/Report or the plan, among other things, using standardized forms (Form 5500 Annual Return/Report or the
Form 5500-SF). This rule proposes that a group health plan subject to ERISA that complies with Form 5500-SF). This rule proposes that a group health plan subject to ERISA that complies with
these reporting requirements would satisfy the quality reporting requirements in PHSA Section these reporting requirements would satisfy the quality reporting requirements in PHSA Section
2717, as incorporated in ERISA. To date, this proposal has not been finalized through 2717, as incorporated in ERISA. To date, this proposal has not been finalized through
rulemaking.rulemaking.
Once the reporting requirements are implemented, plans would submit annually, to the HHS Once the reporting requirements are implemented, plans would submit annually, to the HHS
Secretary (and to DOL and the Department of the Treasury) and to enrollees, a report addressing Secretary (and to DOL and the Department of the Treasury) and to enrollees, a report addressing
whether plan benefits and reimbursement structures do the following:whether plan benefits and reimbursement structures do the following:
 Improve health outcomes through the use of quality reporting, case management, Improve health outcomes through the use of quality reporting, case management,
care coordination, and chronic disease managementcare coordination, and chronic disease management
 Implement activities to prevent hospital readmissions, improve patient safety, and Implement activities to prevent hospital readmissions, improve patient safety, and
reduce medical errorsreduce medical errors
 Implement wellness and health-promotion Implement wellness and health-promotion activities114
activities¹¹⁸ The HHS Secretary is required to make these reports available to the public and is permitted to The HHS Secretary is required to make these reports available to the public and is permitted to
impose penalties for noncompliance.impose penalties for noncompliance.
Large-group, small-group, self-insured, and Large-group, small-group, self-insured, and non-groupnongroup plans are subject to this requirement. plans are subject to this requirement.
Reporting Requirements Regarding Air Ambulances
HHS, in consultation with the Department of Transportation, was required to issue rulemaking no HHS, in consultation with the Department of Transportation, was required to issue rulemaking no
later than one year after enactment of the No Surprises Act indicating how plans should submit later than one year after enactment of the No Surprises Act indicating how plans should submit
specified air ambulance information to the federal government.specified air ambulance information to the federal government.115119 A proposed rule regarding this A proposed rule regarding this
requirement was published on September 16, 2021, but a final rule had not been published as of requirement was published on September 16, 2021, but a final rule had not been published as of
the date of this report.116

113 DOL, Employee Benefits Security Administration, “Annual Reporting and Disclosure,” Proposed Rule, 81 Federal
Register 47495, July 21, 2016.
114 Wellness and health-promotion activities include personalized wellness and prevention services, specifically efforts
related to smoking cessation, weight management, stress management, physical fitness, nutrition, heart disease
prevention, healthy lifestyle support, and diabetes prevention. These services may be made available by entities (e.g.,
health care providers) that conduct health risk assessments or provide ongoing face-to-face, telephonic, or web-based
intervention efforts for program participants.
115 §106(d) of the No Surprises Act, part of the Consolidated Appropriations Act, 2021 (P.L. 116-260).
116 Office of Personnel Management; Treasury, Internal Revenue Service; DOL, Employee Benefits Security
Administration; HHS, CMS, “Requirements Related to Air Ambulance Services, Agent and Broker Disclosures, and
Provider Enforcement,” Proposed Rule, 86 Federal Register 51730, September 16, 2021.
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the date of this report.¹²⁰ Once the final rule is promulgated, plans would be required to report air ambulance claims data Once the final rule is promulgated, plans would be required to report air ambulance claims data
and other specified information regarding air ambulance providers to the federal government for and other specified information regarding air ambulance providers to the federal government for
two consecutive plan years.two consecutive plan years.117
121 HHS, in consultation with the Department of Transportation, is required to summarize the HHS, in consultation with the Department of Transportation, is required to summarize the
information submitted by plans to develop a report that is made available to the public.information submitted by plans to develop a report that is made available to the public.118
122 Large-group, small-group, self-insured, and Large-group, small-group, self-insured, and non-groupnongroup plans are subject to this requirement. plans are subject to this requirement.
Reporting Requirements Regarding Pharmacy Benefits and Drug Costs
Plans are required to annually submit specified information on prescription drug and total health Plans are required to annually submit specified information on prescription drug and total health
care spending to HHS, DOL, and Treasury.care spending to HHS, DOL, and Treasury.119123 This information includes, but is not limited to, the This information includes, but is not limited to, the
plan’plan's 50 brand prescription drugs most frequently dispensed by pharmacies; the plans 50 brand prescription drugs most frequently dispensed by pharmacies; the plan’'s 50 most s 50 most
costly prescription drugs by total annual spending; the plancostly prescription drugs by total annual spending; the plan’'s 50 prescription drugs with the s 50 prescription drugs with the
greatest increase in plan spending; total health care spending broken down by specified greatest increase in plan spending; total health care spending broken down by specified
categories; and categories; and impacts on premiums bythe impacts of rebates, fees, and other remuneration paid by drug rebates, fees, and other remuneration paid by drug
manufactures to the plan manufactures to the plan for enrollees.120
(or its administrators or service providers) on plan premiums and cost-sharing.¹²⁴ HHS, DOL, and Treasury are required to biannually issue a public, online report on prescription HHS, DOL, and Treasury are required to biannually issue a public, online report on prescription
drug reimbursements, prescription drug pricing trends, and the role of prescription drug costs in drug reimbursements, prescription drug pricing trends, and the role of prescription drug costs in
contributing to premium increases or decreases.contributing to premium increases or decreases.
Large-group, small-group, self-insured, and Large-group, small-group, self-insured, and non-groupnongroup plans are subject to this requirement. plans are subject to this requirement.
Transparency in Coverage
Plans are required to satisfy certain disclosure and reporting requirements relating to price Plans are required to satisfy certain disclosure and reporting requirements relating to price
transparency.transparency.121125 Plans are required to publicly post on a website, and Plans are required to publicly post on a website, and to monthly update, three monthly update, three
machine-readable files that separately includemachine-readable files that separately include
 in-network rates with providers for all covered servicesin-network rates with providers for all covered services,
 and items (except prescription drugs that are subject to a fee-for-service reimbursement arrangement), out-of-network allowed amounts and billed charges for covered services out-of-network allowed amounts and billed charges for covered services and items during a during a
specific time period, andspecific time period, and
 negotiated rates and historical net prices for covered prescription drugs.negotiated rates and historical net prices for covered prescription drugs.
HHS, DOL and Treasury have deferred enforcement of the prescription drug machine-readable
file component of this requirement.122

Plans are currently posting in-network rate and out-of-network allowed amount files. The Departments intend to develop an implementation timeline for the prescription drug machine-readable file, which had yet to be developed by the date of this report.¹²⁶

Large-group, small-group, self-insured, and Large-group, small-group, self-insured, and non-groupnongroup plans are subject to this requirement.

Footnotes

1.

Some Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended) provisions were amendments or expansions of Health Insurance Portability and Accountability Act (HIPAA; P.L. 104-191) private health insurance provisions.

2.

See, for example, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (P.L. 110-343).

3.

Requirements summarized in this report are not grouped according to the laws establishing them. In this report, the term surprise billing refers to specified situations where an individual is unknowingly, and potentially unavoidably, treated by a provider outside of the consumer's health insurance plan network and, as a result, unexpectedly receives a larger bill than the individual would have received if the provider had been in the plan network. A consumer may be surprised to receive larger-than-expected medical bills for other reasons; for example, the surprise component may arise because a consumer misunderstands the terms of his or her health insurance policy and receives a bill for an unexpected amount. Such other reasons generally are outside the scope of this report and are not included in this report's usage of the term surprise billing.

4.

An exception is discussed in the student health insurance coverage section in CRS Report R46003, Applicability of Federal Requirements to Selected Health Coverage Arrangements.

5.

For more information, see CRS Report R43922, Federal Employees Health Benefits (FEHB) Program: An Overview, and the self-insured, nonfederal governmental plans section in CRS Report R46003, Applicability of Federal Requirements to Selected Health Coverage Arrangements.

6.

For more information, see CRS Report R44065, Overview of Health Insurance Exchanges.

7.

For more information on these and other types of plans, see CRS Report R46003, Applicability of Federal Requirements to Selected Health Coverage Arrangements.

8.

15 U.S.C. §§1011 et seq. For simplicity, this report generally uses the term insurers to include insurance carriers or issuers and other state-licensed firms.

9.

With respect to health insurers, the Public Health Service Act (PHSA) allows states to be the primary enforcers of the federal private health insurance requirements, but the Secretary of the Department of Health and Human Services (HHS) assumes this responsibility if the Secretary has determined that a state has failed to "substantially enforce" the federal PHSA provisions. For more information on enforcement of private health insurance requirements, see CRS Report R46637, Federal Private Health Insurance Market Reforms: Legal Framework and Enforcement.

10.

Most people with private health insurance have a major medical plan. Major medical plans provide comprehensive health benefits compared with limited benefit plans, although the specific covered benefits may vary across major medical plans. One example of a limited benefit plan is an excepted benefit plan, such as a dental-only or vision-only plan. For more information on these and other types of plans, see CRS Report R46003, Applicability of Federal Requirements to Selected Health Coverage Arrangements.

11.

In this report, references to plans include applicable group health plans and insurers.

12.

This report does not include the full range of federal requirements generally applicable to employee benefit plans, such as fiduciary requirements. Employee benefit plans include group health plans but also may include other types of benefits (e.g., retirement plans).

13.

42 U.S.C. §300gg-1.

14.

Nongroup plans that choose to establish an open enrollment period must apply the same period to plans inside and outside the health insurance exchanges. The open enrollment period rules applicable to exchanges are codified at 45 C.F.R. §155.410. Group plans must allow enrollment during any time of the year, with an exception for small-group plans. Small-group plans may limit enrollment to an annual period from November 15 through December 15 of each year if the plan sponsor does not comply with provisions relating to employer-contribution or group-participation rules, pursuant to state law; see 45 C.F.R. §147.104(b). Qualifying events for special enrollment periods are defined in §603 of the Employee Retirement Income Security Act of 1974 (ERISA; P.L. 93-406) and in 45 C.F.R. §155.420(d).

15.

A waiting period refers to an amount of time that must pass before an individual becomes eligible to enroll under the terms of the plan. A federal requirement specifically concerning the duration of waiting periods is discussed later in this report (see "Waiting Period Limitation").

16.

26 U.S.C. §4980H. For more information, see CRS Report R45455, The Affordable Care Act's (ACA's) Employer Shared Responsibility Provisions (ESRP).

17.

42 U.S.C. §300gg-4(a).

18.

42 U.S.C. §§300gg–3 and 300gg–4, and 45 C.F.R. §§147.110 and 146.121.

19.

42 U.S.C. §300gg-14.

20.

Fully insured plans are subject to the nondiscrimination requirement codified at 42 U.S.C. §300gg-16 (and incorporated by reference into ERISA and the Internal Revenue Code). Self-insured plans are subject to the nondiscrimination requirement codified at 26 U.S.C. §105(h).

21.

42 U.S.C. §300gg-7.

22.

42 U.S.C. §300gg-2.

23.

42 U.S.C. §300gg-12.

24.

This requirement was established under Title X of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA; P.L. 99-272). Coverage received under this requirement is typically referred to as COBRA coverage.

25.

29 U.S.C. §§1161-1168. An example of a qualifying event is termination from a job.

26.

42 U.S.C. §300gg–28.

27.

P.L. 110-381.

28.

For the sake of simplicity, the use of the term premium in this report broadly applies not only to the final amounts paid by consumers and others for coverage but also the prices for insurance products that health insurance issuers determine as they develop final premium amounts.

29.

42 U.S.C. §300gg-4(b). For information about identifying similarly situated individuals, see 45 C.F.R. §146.121(d).

30.

42 U.S.C. §300gg-4(j).

31.

42 U.S.C. §300gg.

32.

Federal law allows states to impose additional rating requirements, provided the state requirements neither conflict with federal law nor prevent the implementation of federal requirements. For more information about state rating requirements, see Centers for Medicare & Medicaid Services (CMS), Center for Consumer Information & Insurance Oversight (CCIIO), "Market Rating Reforms: State Specific Rating Variations," at https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Market-Reforms/state-rating.

33.

45 C.F.R. §147.102(b). A three-digit zip code refers to the first three digits of a five-digit zip code. A three-digit zip code represents a larger geographical area than a five-digit zip code, as all five-digit zip codes that share the same first three numbers are included in the three-digit zip code.

34.

For the federal default and state-specific age rating ratios, see CCIIO, "Market Rating Reforms: State Specific Age Curve Variations," at https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Market-Reforms/state-rating.html#age.

35.

42 U.S.C. §300gg-94. CMS identifies whether states have effective rate review systems. In states with effective rate review systems, the state conducts review; in states that do not have effective rate review systems, CMS conducts the review.

36.

45 C.F.R. §§154.101 and 154.200. The federal default threshold was 10% in previous years. It was modified by HHS, "HHS Notice of Benefit and Payment Parameters for 2019," 83 Federal Register 16930, April 17, 2018.

37.

Any state that wishes to apply a higher threshold than the federal default must submit a proposal for approval to the HHS Secretary. Since states generally are allowed to enact stricter requirements compared with relevant federal provisions, states may impose a rate review threshold that is lower than the federal default on their own without approval from the Secretary. For more information, see CMS, CCIIO, "State-Specific Threshold Proposals," at https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Market-Reforms/sst.

38.

45 C.F.R. §§154.101 and 154.200.

39.

See the appendix of CRS Report R47507, Private Health Insurance: A Primer for further discussion of health insurance risk and risk pools.

40.

42 U.S.C. §18032(c) and 45 C.F.R. §156.80.

41.

42 U.S.C. §300gg-18.

42.

To view a list of state requests for a medical loss ratio adjustment, see CMS, CCIIO, "State Requests for MLR Adjustment," at https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Market-Reforms/state_mlr_adj_requests.

43.

42 U.S.C. §§300gg-6 and 18022.

44.

The 10 categories of essential health benefits (EHB) are ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.

45.

42 U.S.C. §18022(b).

46.

45 C.F.R. §§156.100 et seq. For more information on the process for defining the EHB in each state, as well as each state's benchmark plan, see CMS, CCIIO, "Information on Essential Health Benefits (EHB) Benchmark Plans," at https://www.cms.gov/marketplace/resources/data/essential-health-benefits.

47.

45 C.F.R. §156.115(a)(1).

48.

See, for example, 45 C.F.R. §§156.115 and 156.122.

49. 42 U.S.C. §300gg-13; 45 C.F.R. §147.130. The complete list of preventive services required to be covered, per all of the categories of recommendations, is available at HealthCare.gov, "Preventive Health Services," at http://www.healthcare.gov/coverage/preventive-care-benefits/. 50.

U.S. Preventive Services Task Force, "A & B Recommendations," at https://uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations.

51. Advisory Committee on Immunization Practices (ACIP), "ACIP Vaccine Recommendations and Guidelines: Vaccine-Specific Recommendations," at https://www.cdc.gov/acip-recs/hcp/vaccine-specific/. Also see CDC, "Immunization Schedules," at https://www.cdc.gov/vaccines/hcp/imz-schedules/. See 45 C.F.R. §147.130(a)(1)(ii) regarding ACIP recommendations being considered "in effect" and "for routine use" for purpose of this coverage requirement. 52.

Health Resources and Services Administration (HRSA), "Bright Futures," at https://mchb.hrsa.gov/programs-impact/bright-futures. See linked "Periodicity Schedule."

53. HRSA, "Women's Preventive Services Guidelines," at https://www.hrsa.gov/womens-guidelines. Also see Women's Preventive Services Initiative (WPSI), "Recommendations," at https://www.womenspreventivehealth.org/recommendations/. For additional information about this and the other categories of recommendations, see the "Federal Regulation of Private Health Insurance" section of CRS Report R46785, Federal Support for Reproductive Health Services: Frequently Asked Questions. That section of the report includes general discussion of the preventive services coverage requirement and particular aspects of the requirement (such as coverage of contraceptive services and supplies, per HRSA-supported recommendations on preventive services for women). 54.

See 45 C.F.R. §147.130(b).

55.

Whether cost sharing for office visits is allowed generally depends on whether the preventive service or item is the primary purpose of the visit and whether the service or item is billed or tracked separately from the office visit. See 45 C.F.R. §147.130(a)(2).

56.

45 C.F.R. §147.130(a)(3).

57.

45 C.F.R. §147.130(a)(4).

58.

42 U.S.C. §300gg-13, Statutory Note, "Rapid Coverage of Preventive Services and Vaccines for Coronavirus."

59.

For additional discussion of this requirement, see CRS Report R46359, COVID-19 and Private Health Insurance Coverage: Frequently Asked Questions. As that report also discusses, the Coronavirus Disease 2019 (COVID-19) vaccination coverage requirement is not time-limited, but a separate requirement regarding private health insurance coverage of COVID-19 testing is limited to the duration of the declared public health emergency. For that reason, the testing coverage requirement is not otherwise included in this report. There are no federal requirements specific to private health insurance coverage of COVID-19 treatments, but other requirements may be applicable (e.g., coverage of the EHB).

60.

For purposes of this provision, a qualified individual is an individual who (1) is eligible to participate in an approved clinical trial for treatment of cancer or other life-threatening disease or condition and (2) has a referring health care provider who either has concluded that the individual's participation is appropriate or provides medical and scientific information establishing that participation in a clinical trial would be appropriate.

61.

42 U.S.C. §300gg-8.

62.

42 U.S.C. §300gg–25. There is an exception to the length-of-coverage requirement when providers make earlier discharge decisions in consultation with mothers. Plans are prohibited from offering incentives or penalties to providers or mothers to encourage shorter stays.

63.

Some insurers include prior authorization requirements for certain covered benefits. For example, they may require enrollees to obtain prior authorization from the insurer for routine hospital inpatient care, as a condition for covering the care.

64.

42 U.S.C. §300gg–26. For more information on parity requirements, see CRS Report R47402, Mental Health Parity and Coverage in Private Health Insurance: Federal Requirements.

65.

45 C.F.R. §146.136.

66.

42 U.S.C. §300gg–26(a)(4).

67.

42 U.S.C. §300gg–26(a)(8).

68.

Although the small employer exemption initially applied to both fully insured and self-insured plans, EHB and parity regulations have provided that plans subject to EHB requirements (including fully insured plans offered by small employers) are also subject to parity requirements. Small employers (defined for this purpose as those with 50 or fewer employees) that self-insure are still exempt from parity requirements. For discussion of these details and the separate exemption regarding increased costs, see the Department of the Treasury, Department of Labor (DOL), and HHS, "Final Rules Under the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008; Technical Amendment to External Review for Multi-State Plan Program," 78 Federal Register 68239, November 13, 2013, starting at page 68248.

69.

42 U.S.C. §300gg–27.

70.

See Employee Benefits Security Administration, "Compliance Assistance Guide: Health Benefits Coverage Under Federal Law." September 2014, at https://www.dol.gov/sites/dolgov/files/ebsa/about-ebsa/our-activities/resource-center/publications/compliance-assistance-guide.pdf. Also see DOL, HHS, and Department of the Treasury, "FAQs About Affordable Care Act Implementation Part 31, Mental Health Parity Implementation, And Women's Health And Cancer Rights Act Implementation," April 20, 2016, at https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/FAQs-31_Final-4-20-16.pdf.

71.

42 U.S.C. §2000e; 29 C.F.R. §1604.10, and 29 C.F.R. §1604, Appendix to Part 1604—Questions and Answers on the Pregnancy Discrimination Act, P.L. 95-555, 92 Stat. 2076 (1978). See CRS Report R46785, Federal Support for Reproductive Health Services: Frequently Asked Questions for additional information and citations.

72.

42 U.S.C. §300gg-3.

73.

Prior to the ACA, some plans were allowed to exclude benefits for preexisting conditions during what was referred to as an exclusion period. This is different from a waiting period (see the "Waiting Period Limitation" section of this report).

74.

In general, beginning with each plan year, an enrollee pays 100% of costs for covered health care benefits until the costs meet a certain threshold amount, called a deductible. Exceptions apply. After reaching the deductible, the enrollee pays coinsurance (a percentage amount) or co-payments (a flat amount) for covered benefits and the plan pays the rest. If an enrollee's spending meets an annual out-of-pocket limit, the plan generally will pay 100% of covered costs for the remainder of the plan year.

75.

42 U.S.C. §300gg-6 and 18022.

76.

See, for example, CMS, CCIIO, "Premium Adjustment Percentage, Maximum Annual Limitation on Cost Sharing, Reduced Maximum Annual Limitation on Cost Sharing, and Required Contribution Percentage for the 2025 Benefit Year," November 15, 2023, at https://www.cms.gov/files/document/2025-papi-parameters-guidance-2023-11-15.pdf.

77.

See CRS Report R44065, Overview of Health Insurance Exchanges for these and prior year annual limits.

78.

For example, for a family of three enrolled in a plan with the 2025 limits: Once individual 1 incurs $9,200 in cost sharing for his or her benefits as specified above (generally, on in-network EHB), the plan is responsible for 100% of the costs for such benefits for the rest of the plan year. However, if individuals 2 and 3 have incurred only $2,000 each in cost sharing, they would still be responsible for cost sharing at that time. If any combination of the enrollees' cost sharing adds up to $18,400, then the plan would be responsible for 100% of all of the enrollees' costs for covered benefits for the rest of the plan year. For additional information about the annual OOP limit, see CMS, CCIIO, "Embedded Self-Only Annual Limitation on Cost Sharing FAQs," May 8, 2015, at https://www.dol.gov/sites/default/files/ebsa/laws-and-regulations/laws/affordable-care-act/for-employers-and-advisers/hhs-guidance-embedded-self-only-annual-limitation-on-cost-sharing-faqs.pdf.

79.

45 C.F.R. §156.130. Also see HHS, DOL, and Treasury, "Affordable Care Act Implementation FAQs – Set 18," January 9, 2014, at https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/aca_implementation_faqs18, including questions 2 and 4. Hereinafter referred to as Tri-Agency FAQ 18.

80.

See, for example, "Preventing Surprise Medical and Air Ambulance Bills." Also see 45 C.F.R. §156.130(h) regarding prescription drug coupons.

81.

This requirement applies to EHB coverage, and large-group and self-insured plans are not required to cover the EHB. The Tri-Agency FAQ 18, question 2, provides that such plans must use a permissible definition of EHB (including any state-selected EHB benchmark plan) to determine whether they comply with this requirement. This is consistent with regulations implementing the separate "Prohibition on Lifetime and Annual Coverage Limits".

82. See the definition of actuarial value in the glossary on HealthCare.gov at https://www.healthcare.gov/glossary/actuarial-value/. 83.

42 U.S.C. §300gg-6 and 18022.

84.

Regulations allow plans to fall within a specified actuarial value range and still comply with one of the four levels; see 45 C.F.R. §156.140(c)(2).

85.

45 C.F.R. §§156.20 and 156.135.

86.

42 U.S.C. §300gg-11; 45 C.F.R. §147.126.

87.

This requirement applies to EHB coverage, and large-group and self-insured plans are not required to cover the EHB. Regulations provide that such plans must use a permissible definition of EHB (including any state-selected EHB benchmark plan) to determine whether they comply with this requirement. See 45 C.F.R. §147.126(c).

88.

42 U.S.C. §§300gg-111 and 300gg-112. For more information on the topic of surprise billing, including these federal requirements, see CRS Report R46856, Surprise Billing in Private Health Insurance: Overview of Federal Consumer Protections and Payment for Out-of-Network Services.

89.

For notice and consent requirements, see 42 U.S.C. §300gg-132(d).

90.

With covered, out-of-network air ambulance services specifically, the cost-sharing requirement must be the same as the cost sharing for an in-network provider.

91.

For applicable emergency services and covered nonemergency services provided by an out-of-network provider at an in-network facility, if the service is provided in a state that has an applicable surprise billing law or an all-payer model agreement, the cost-sharing amount is to be calculated in accordance with such law or agreement. See definition of recognized amount at 45 C.F.R. §149.30, as referenced by 45 C.F.R §149.110(b)(3)(iii). For air ambulance services, see 45 C.F.R. §149.130(b)(2).

92.

For more information on the federal payment methodology, see CRS In Focus IF12073, Surprise Billing: Independent Dispute Resolution Process.

93.

42 U.S.C. §300gg-111(a)(1).

94.

42 U.S.C. §300gg-113. For purposes of this provision, a continuing care patient is an individual who satisfies one of the following criteria: (1) is undergoing treatment for a serious and complex condition; (2) is undergoing institutional or inpatient care; (3) is scheduled to undergo nonelective surgery; (4) is pregnant and undergoing a course of treatment for the pregnancy; or (5) is or was determined to be terminally ill and is receiving treatment for such illness.

95.

42 U.S.C. §300gg-115(b).

96.

42 U.S.C. §300gg-117.

97.

42 U.S.C. §300gg-5.

98.

This component of the requirement applies to group health plans only.

99.

42 U.S.C. §300gg-119. The term business associate is defined at 45 C.F.R. §160.103.

100.

42 U.S.C. §300gg-15; 45 C.F.R. §147.200. In addition, there is a separate requirement on group plans to provide a Summary Plan Description (SPD) to enrollees. SPD requirements are applicable to employee benefit plans, which includes group health plans but also may include other types of benefits (e.g., retirement plans). In general, this CRS report focuses on requirements specific to health insurance and group health plans. For information about SPD and other disclosure requirements on employee benefit plans, including certain additional disclosure requirements for group health plans (such as the SBC requirement), see DOL, Employee Benefits Security Administration (EBSA), Reporting and Disclosure Guide for Employee Benefit Plans, December 2022, at https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/publications/reporting-annual-disclosure.pdf.

101.

Good-faith cost estimates are required to be provided when care is scheduled at least three business days in advance (or upon request of the enrollee). 42 U.S.C. §300gg-136.

102.

42 U.S.C. §300gg-111(f).

103.

The term medical management technique includes concurrent review, prior authorization, and step-therapy or fail-first protocols. 42 U.S.C. §300gg-111(f)(1)(F).

104.

DOL, HHS, and Treasury, "FAQs Part 49."

105.

42 U.S.C. §300gg-111(e).

106.

42 U.S.C. §§300gg-114 and 300gg-15a, and 45 C.F.R. §147.211.

107.

Plans may limit price comparison information to a limited set of providers when providing information in paper format. 45 C.F.R. §147.211.

108.

42 U.S.C. §300gg-115(a).

109.

More specifically, the requirements on plans at 42 U.S.C. §300gg-111 and the requirements on providers prohibiting balance billing in certain circumstances at 42 U.S.C. §§300gg-131 and 300gg-132. The term balance billing, which is one type of surprise bill, refers to amounts that an out-of-network provider can charge a consumer for care that is in addition to the amount the consumer pays in out-of-network cost sharing and the amounts that the provider receives from a plan for such services. For more information on the relationship between surprise bills and balance bills, see the "Private Health Insurance Billing Overview" in CRS Report R46856, Surprise Billing in Private Health Insurance: Overview of Federal Consumer Protections and Payment for Out-of-Network Services. For a discussion of the surprise billing requirements at 42 U.S.C. §300gg-111 regarding out-of-network emergency services and covered, nonemergency services provided by an out-of-network provider at an in-network facility (when notice and consent requirements have not been satisfied), see "Preventing Surprise Medical and Air Ambulance Bills."

110.

42 U.S.C. §300gg-115(c).

111.

42 U.S.C. §300gg-19b. Pharmacy benefit managers (PBMs) are intermediaries between health plans and pharmacies, drug wholesalers, and manufacturers. PBMs perform functions such as designing drug formularies, negotiating prices, and administering prescription drug payment systems.

112.

For more information on prescription drug coupons and patient assistance programs, see CRS Report R44264, Prescription Drug Discount Coupons and Patient Assistance Programs (PAPs).

113.

42 U.S.C. §300gg-46. Separately, disclosure provisions require those providing "brokerage services" or "consulting" to group health plans to disclose specified information, including information regarding direct and indirect compensation, to plan fiduciaries. See 29 U.S.C. §1108(b)(2).

114.

42 U.S.C. §300gg-19(a).

115.

42 U.S.C. §300gg-19(b).

116.

42 U.S.C. §300gg-17.

117.

DOL, Employee Benefits Security Administration, "Annual Reporting and Disclosure," Proposed Rule, 81 Federal Register 47495, July 21, 2016.

118.

Wellness and health-promotion activities include personalized wellness and prevention services, specifically efforts related to smoking cessation, weight management, stress management, physical fitness, nutrition, heart disease prevention, healthy lifestyle support, and diabetes prevention. These services may be made available by entities (e.g., health care providers) that conduct health risk assessments or provide ongoing face-to-face, telephonic, or web-based intervention efforts for program participants.

119.

Section 106(d) of the No Surprises Act, part of the Consolidated Appropriations Act, 2021 (P.L. 116-260).

120.

Office of Personnel Management; Treasury, Internal Revenue Service; DOL, Employee Benefits Security Administration; HHS, CMS, "Requirements Related to Air Ambulance Services, Agent and Broker Disclosures, and Provider Enforcement," Proposed Rule, 86 Federal Register 51730, September 16, 2021.

121.

42 U.S.C. §300gg-118.

122.

Section 106(c) of the No Surprises Act, part of the Consolidated Appropriations Act, 2021 (P.L. 116-260).

123.

42 U.S.C. §300gg-120.

124.

Regulations provide further specification for how plans are to meet this requirement. See Office of Personnel Management; Treasury, Internal Revenue Service; DOL, Employee Benefits Security Administration; HHS, CMS, "Prescription Drug and Health Care Spending," Interim Final Rule, 86 Federal Register 66662, November 23, 2021.

125.

42 U.S.C. §300gg-15a and 45 C.F.R. §147.212.

126.

DOL, HHS, and Department of the Treasury, "FAQs About Affordable Care Act Implementation Part 61," September 27, 2023, at https://www.cms.gov/files/document/faqs-about-affordable-care-act-implementation-part-61.pdf.

plans are subject to this requirement.


117 42 U.S.C. §300gg-118.
118 §106(c) of the No Surprises Act, part of the Consolidated Appropriations Act, 2021 (P.L. 116-260).
119 42 U.S.C. §300gg-120.
120 Regulations provide further specification for how plans are to meet this requirement. See Office of Personnel
Management; Treasury, Internal Revenue Service; DOL, Employee Benefits Security Administration; HHS, CMS,
“Prescription Drug and Health Care Spending,” Interim Final Rule, 86 Federal Register 66662, November 23, 2021.
121 42 U.S.C. §300gg-15a and 45 C.F.R. §147.212.
122 DOL, HHS, and Treasury, “FAQs Part 49.”
Congressional Research Service

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Federal Requirements on Private Health Insurance Plans


Author Information

Ryan J. Rosso, Coordinator
Bernadette Fernandez
Analyst in Health Care Financing
Specialist in Health Care Financing


Vanessa C. Forsberg
Katherine M. Kehres
Analyst in Health Care Financing
Analyst in Health Care Financing




Disclaimer
This document was prepared by the Congressional Research Service (CRS). CRS serves as nonpartisan
shared staff to congressional committees and Members of Congress. It operates solely at the behest of and
under the direction of Congress. Information in a CRS Report should not be relied upon for purposes other
than public understanding of information that has been provided by CRS to Members of Congress in
connection with CRS’s institutional role. CRS Reports, as a work of the United States Government, are not
subject to copyright protection in the United States. Any CRS Report may be reproduced and distributed in
its entirety without permission from CRS. However, as a CRS Report may include copyrighted images or
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copy or otherwise use copyrighted material.

Congressional Research Service
R45146 · VERSION 6 · UPDATED
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