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Overview of Private Health Insurance
Provisions in the Patient Protection and
Affordable Care Act (ACA)
Annie L. Mach
Analyst in Health Care Financing
Namrata K. Uberoi
Analyst in Health Care Financing
January 8, 2015
Congressional Research Service
7-5700
www.crs.gov
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Summary
Private health insurance (PHI) is the predominate form of health insurance coverage in the United
States, covering about two-thirds of Americans in 2013. The Patient Protection and Affordable
Care Act (ACA; P.L. 111-148, as amended) builds on existing sources of private health insurance
coverage—the nongroup (individual), small group, and large group markets. The ACA private
health insurance provisions follow a federalist model in which they establish federal minimum
requirements and give states the authority to enforce and expand those federal standards.
The ACA includes provisions that restructure the private health insurance market by
1. implementing market reforms that impose requirements on insurers and sponsors
of health insurance (e.g., employers);
2. instituting a core set of benefits and services (i.e., the essential health benefits);
3. establishing an individual mandate that requires most individuals to either
maintain health insurance coverage or pay a penalty;
4. creating exchanges (marketplaces) in which individuals and small businesses can
shop for and purchase health plans that meet or exceed federal standards;
5. providing financial assistance to qualified individuals who purchase health plans
through an exchange; and
6. assessing penalties on certain employers that either do not provide health
insurance or provide health insurance that is unaffordable or does not provide
minimum value.
This report provides a broad overview of the PHI provisions in the ACA and directs readers to
more in-depth CRS reports.
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Contents
Background ...................................................................................................................................... 1
Private Health Insurance Market Reforms ....................................................................................... 2
Essential Health Benefits Package ................................................................................................... 4
Individual Mandate .......................................................................................................................... 5
Exchanges (Marketplaces) ............................................................................................................... 7
Individual Exchange and Financial Assistance ......................................................................... 7
Premium Tax Credits ........................................................................................................... 8
Cost-Sharing Subsidies ....................................................................................................... 9
Small Business Health Options Program Exchange .................................................................. 9
Small Business Tax Credit ................................................................................................ 10
Employer Requirements and Penalties Related to the Offer of Insurance ..................................... 11
Consumer Operated and Oriented Plan Program ........................................................................... 11
Multi-State Plan Program .............................................................................................................. 12
State Options .................................................................................................................................. 13
Basic Health Program .............................................................................................................. 13
Waiver for State Innovation ..................................................................................................... 14
Health Care Choice Compacts ................................................................................................. 14
Risk Mitigation Programs .............................................................................................................. 14
Tables
Table 1. Patient Protection and Affordable Care Act (ACA) Private Health Insurance
Market Reforms ............................................................................................................................ 3
Table 2. Individual Mandate Penalty ............................................................................................... 6
Table 3. Description of the Patient Protection and Affordable Care Act (ACA) Risk
Mitigation Programs ................................................................................................................... 15
Contacts
Author Contact Information........................................................................................................... 16
Acknowledgments ......................................................................................................................... 17
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Background
Americans obtain health insurance coverage in different settings and through a variety of
methods. Although many receive coverage through publicly funded programs (e.g., Medicare and
Medicaid), private health insurance is the predominate form of health coverage in the United
States. The private market is often described as having three segments: nongroup (individual),
small group, and large group.1 In 2013, about 64.2% of the population had private health
insurance.2 Most individuals and families obtain private insurance through small or large group
coverage, such as employer-sponsored insurance; some individuals and families may purchase
private insurance on their own in the nongroup market.
The Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended) includes
several provisions that affect the private health insurance market. These provisions create federal
rules and incentives for entities and individuals in the market that build on and modify the
existing market structure. Collectively, the provisions reflect the ACA’s general goal of increasing
access to health insurance coverage.
The ACA also includes an individual mandate, which requires most individuals to maintain health
insurance coverage or pay a penalty for noncompliance. Many have argued that unless healthy
individuals are encouraged to participate in the private market, insurance pools will primarily
consist of individuals who are high users of health care services, potentially creating financially
unstable situations for insurers and enrollees.3 As of January 1, 2014, most individuals are
required to maintain health insurance coverage or otherwise pay a penalty.
Under the ACA, nearly all individuals can obtain private coverage regardless of preexisting
conditions or health status and insurers have limited ability to vary premiums based on an
applicant’s health status and other characteristics. To help accommodate individuals who have
access to private health insurance as a result of these (and other) provisions, individuals and small
businesses can shop for and purchase private coverage in health insurance exchanges
(marketplaces). Additionally, some individuals can receive financial assistance toward coverage
obtained in an exchange.
The ACA provides financial incentives for employers to consider when determining whether to
offer employer-based health insurance to employees. Some small employers are eligible to
receive tax credits for their contributions toward their employees’ health insurance premiums.
Certain large employers are subject to a shared responsibility provision. This provision does not
explicitly mandate that a large employer offer employees health insurance; instead, it has the
1 What constitutes large and small in the private market varies. Often, for the purpose of state and federal laws, a large
employer has 50 or more employees and a small employer has up to 50 employees. The definitions of small and large
also vary under the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended), but most often the
ACA defines small as either up to 50 or up to 100 employees.
2 U.S. Census Bureau, Current Population Survey, “Health Insurance Coverage in the United States: 2013,” September
2014, available at http://www.census.gov/content/dam/Census/library/publications/2014/demo/p60-250.pdf.
3 The intent of health insurance is to minimize the potential financial risk associated with use of health care services.
One way to minimize risk in the insurance market is to spread risk among a group of people. This concept is often
called risk pooling. A group of individuals contributes to a common pool (risk pool), and contributions from low-cost
individuals in the pool (i.e., individuals who use few medical services) subsidize the medical costs of higher-cost
individuals in the pool.
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potential to impose penalties on large employers that do not provide affordable and adequate
coverage to their employees. The shared responsibility provision was slated to take effect in 2014,
but its implementation was delayed until 2015.
This report describes various ACA provisions that affect the private insurance market. It does not
provide exhaustive information about each provision, but it includes references to Congressional
Research Service (CRS) reports that contain detailed information.
Private Health Insurance Market Reforms
A number of ACA provisions
Exemptions from ACA Market Reforms
focus on changing how insurers
Grandfathered Status
and sponsors of insurance (e.g.,
employers) offer coverage.
Health insurance plans that were in existence (either in the group or
Collectively, the market reforms
nongroup market) and in which at least one person was enrolled on the
date of the ACA’s enactment (March 23, 2010) are considered
establish federal minimum
grandfathered and have a unique status under the ACA. As long as a plan
requirements regarding access to
maintains its grandfathered status, the plan has to comply with some but
coverage, premiums,4 benefits,
not all ACA provisions. Plans may lose their status if they apply certain
cost-sharing,5 and consumer
changes to benefits, cost-sharing, employer contributions, and access to
coverage.
protections while generally
giving states the authority to
For more information about grandfathered plans and their requirements
enforce the reforms and the
under ACA, see CRS Report R41166, Grandfathered Health Plans Under
the Patient Protection and Affordable Care Act (ACA).
ability to expand on the reforms.6
Some of the reforms apply to all
Transitional Policy
three segments of the private
On March 5, 2014, the Centers for Medicare and Medicaid Services
insurance market (nongroup,
(CMS) extended a transitional policy that was first described in guidance
small group, and large group),
issued by CMS in November 2013. Under the transitional policy, health
insurance issuers offering non-grandfathered coverage in the nongroup
but many of the reforms focus
and small group markets may choose to continue coverage that would
specifically on the nongroup and
otherwise be canceled. Pursuant to the policy, state insurance
small group insurance markets.
commissioners may choose whether to enforce compliance with
These reforms are intended to
specified ACA market reforms. Presumably, if state insurance
commissioners choose not to enforce compliance, then issuers may
address perceived failures in
renew coverage for enrol ees who would otherwise receive cancel ation
those markets, such as limited
notices. Pursuant to the extended policy, coverage renewed for a plan
access to coverage and higher
year beginning before or on October 1, 2016, does not have to comply
costs of coverage, and to provide
with certain ACA market reforms, provided the coverage meets
some parity with the large group
specified conditions.
market, which may already have
For more information about transitional policies, see
many of these features.
http://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/
Downloads/transition-to-compliant-policies-03-06-2015.pdf.
Some of the market reforms are
4 A premium is the amount paid for health insurance, often on a monthly basis.
5 Cost-sharing is the share of costs an insured individual pays for services; the term often includes deductibles,
coinsurance, and co-payments. A deductible is the amount an insured individual pays before his or her health insurance
issuer begins to pay for services. Coinsurance is the share of costs, figured in percentage form, an insured individual
pays for a health service. A co-payment is a fixed amount an insured individual pays for a health service.
6 Private health insurance is primarily regulated at the state level. The ACA establishes uniform requirements and
additional options for all states.
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new to certain insurance markets; others have been in place in some capacity due to either state or
federal laws. For example, guaranteed issue is the requirement that an insurer accept every
applicant for coverage as long as the applicant agrees to the terms and conditions of the insurance
offer (e.g., the premium). In the early 1990s, some states passed laws requiring guaranteed issue
in their small group markets, with fewer states adopting types of guaranteed issue laws in their
nongroup markets.7 In 1996, Congress passed the Health Insurance Portability and Accountability
Act (HIPAA; P.L. 104-191), which requires guaranteed issue in the small group market in all
states. The ACA extends these efforts by requiring, as of 2014, that all non-grandfathered
nongroup and group plans (except those that are self-insured)8 offer coverage on a guaranteed
issue basis. However, not all plans are subject to these ACA market reforms (see “Exemptions
from ACA Market Reforms” text box for further information).
Table 1 provides a brief overview of the market reforms in the ACA. More specific information,
including how the reforms apply to each segment of the private market, can be found in CRS
Report R42069, Private Health Insurance Market Reforms in the Affordable Care Act (ACA).
Table 1. Patient Protection and Affordable Care Act (ACA) Private Health Insurance
Market Reforms
ACA Provision
Brief Description
Obtaining Health Insurance
Extension of dependent
Applicable plans that offer dependent coverage must make that coverage available to
coverage
children under the age of 26.
Prohibition of discrimination
Applicable plans are prohibited from establishing eligibility criteria for full-time
based on salary
employees based on salary.
Guaranteed issue
Applicable plans are required to accept every applicant for health coverage (as long as
the applicant agrees to the terms and conditions of the insurance offer).
Nondiscrimination based on
Applicable plans are prohibited from basing eligibility for coverage on health status-
health status
related factors.
Waiting period limitation
Applicable plans cannot establish a waiting period of more than 90 days.
Maintaining Health Insurance
Prohibition on rescissions
Applicable plans are prohibited from rescinding coverage except in cases of fraud or
intentional misrepresentation.
Guaranteed renewability
Applicable plans must renew individual coverage at the option of the policyholder or
group coverage at the option of the plan sponsor.
Cost of Purchasing Health Insurance
7 Mila Kofman and Karen Pollitz, Health Insurance Regulation by States and the Federal Government: A Review of
Current Approaches and Proposals for Change, Georgetown University Health Policy Institute, April 2006.
8 A common distinction in the group market is whether plans are fully insured or self-insured. A fully insured plan is
one in which the insurer or insurance sponsor purchases health coverage and the insurer assumes the risk of providing
health benefits to the sponsor’s enrolled members. A self-insured plan is one in which an entity (e.g., employer or
association) provides coverage for its members directly by setting aside funds and paying for health benefits. Under
self-insurance, the entity bears the risk for covering medical expenses, and self-insured plans are not subject to state
insurance regulations.
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ACA Provision
Brief Description
Review of “unreasonable”
Applicable plans must submit a justification for an “unreasonable” rate increase to the
rate increases
Secretary of Health and Human Services (HHS) and the relevant state prior to
implementation of the increase.
Rating restrictions
Applicable plans can only adjust premiums based on certain ACA-specified factors.
Covered Benefits
Coverage of preventive
Applicable plans are required to provide coverage for preventive health services
health services with no cost-
without cost-sharing.
sharing
Coverage of preexisting
Applicable plans are prohibited from excluding coverage for preexisting health
health conditions
conditions for all individuals.
Limits on Cost-Sharing
Prohibition on lifetime limits
Applicable plans are prohibited from imposing lifetime limits on the dollar value of the
essential health benefits (EHB).
Prohibition on annual limits
Applicable plans are prohibited from imposing annual limits on the dollar value of the
EHB.
Other Consumer Protections
Medical loss ratio
Applicable plans are required to spend a certain amount of premium revenue on
requirement
medical claims or otherwise provide rebates to policyholders.
Standardized appeals process Applicable plans must implement an effective appeals process for coverage
determinations and claims.
Patient protections
Applicable plans must comply with requirements related to choice of health care
professionals and benefits for emergency services.
Summary of benefits and
Applicable plans must provide a summary of benefits and coverage to individuals that
coverage
meets the requirements specified by the HHS Secretary.
Reporting requirements
Applicable plans must annually submit reports to the HHS Secretary and enrollees
regarding quality of care
that address plan quality.
Nondiscrimination regarding
Applicable plans cannot prohibit enrollees from participating in approved clinical
clinical trial participation
trials.
Nondiscrimination regarding
Applicable plans are not allowed to discriminate, with respect to participation under
health care providers
the plan, against health care providers acting within the scope of their license or
certification.
Source: Congressional Research Service (CRS) analysis of the ACA and its implementing regulations.
Essential Health Benefits Package
Both state and federal governments have the authority to require private plans to comply with
specified rules and regulations, such as offering certain benefits and services. The ACA includes a
provision that expands federal requirements with regard to covered benefits and cost-sharing
structures. The ACA requires that all non-grandfathered plans offered in the nongroup and small
group markets (both inside and outside exchanges) offer the essential health benefits (EHB).
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The ACA does not explicitly define the EHB; rather, it lists 10 broad categories from which
benefits and services must be included9 and requires the Secretary of Health and Human Services
(HHS) to further define the EHB. For 2014 and 2015, 10 the HHS Secretary asked states to select a
benchmark plan from four different types of plans.11 Plans that are required to offer the EHB must
model their benefits package after the state’s benchmark plan.12 Plans must supplement their
benchmark plans to ensure that benefits and services from all 10 statutorily required categories
are represented.
The EHB package includes limits on enrollees’ cost-sharing requirements. The ACA specifies that
the limits work in two13 ways: they prohibit (1) applying deductibles to preventive health services
and (2) annual out-of-pocket limits that exceed existing limits in the tax code.14 In 2015, the limit
is $6,600 for an individual plan and $13,200 for a family plan.
Additionally, plans offering the EHB package
must meet one of four levels of generosity of
The ACA and Actuarial Value
coverage based on actuarial value. (See “ACA
Actuarial value is a summary measure of a plan’s
and Actuarial Value” text box for more
generosity of coverage, expressed as a percentage of
medical expenses for a standard population and a set of
information.)
allowed charges estimated to be paid by the issuer. In
other words, actuarial values reflect the relative
The ACA requires plans that offer the EHB
proportions of cost-sharing that may be imposed. On
package to meet one of four generosity levels
average, the lower the actuarial value of a plan, the
(metal tiers):
greater the cost-sharing for the enrol ee.
However, because actuarial value is a summary measure
• bronze—60% actuarial value;
based on a standard population, it is of varying value to
individuals. Its value for an individual depends on how the
• silver—70% actuarial value;
individual’s medical costs align with the costs of the
standard population. Actuarial value also does not take
• gold—80% actuarial value; and
into account aspects of health insurance coverage that
•
may be important to individuals. In particular, it does not
platinum—90% actuarial value.
consider the cost of premiums and the adequacy of
provider networks, and plans with the same actuarial
value do not necessarily include the same set of covered
Individual Mandate
benefits.
As of January 1, 2014, ACA requires that most individuals maintain health insurance coverage or
pay a penalty for noncompliance. To comply with the individual mandate, most individuals need
9 The 10 categories 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.
10 As of the publication date of this report, final 2016 guidance for the essential health benefits has not been released.
11 78 Federal Register 12834, February 25, 2013.
12 Summaries of each state’s selected benchmark plan are available at http://www.cms.gov/CCIIO/Resources/Data-
Resources/ehb.html.
13 The ACA previously limited cost-sharing in three ways. It also included deductible limits for plans offered in the
small group market—generally prohibiting these plans from having deductibles greater than $2,000 for self-only
coverage and $4,000 for any other coverage in 2014. However, the Protecting Access to Medicare Act of 2014 (P.L.
113-93) repealed this provision, thereby removing the limitation on deductibles for plans offered in the small group
market.
14 The existing limits are those that are applicable to high-deductible health plans that qualify to be paired with health
savings accounts. For more information on consumer-driven health care, see CRS Report RL32237, Health Insurance:
A Primer.
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to obtain minimum essential coverage, which includes most types of private (e.g., employer-
sponsored insurance and nongroup coverage) and public coverage (e.g., Medicare and Medicaid).
Certain individuals are exempt from the mandate, including those with qualifying religious
exemptions; those whose household income is less than the filing threshold for federal income
taxes for the applicable tax year; those whose required contribution for self-only coverage for a
calendar year exceeds 8% of household income;15 those who receive a hardship exemption from
the HHS Secretary; and those who are not lawfully present in the United States.
The individual mandate is often described as working in conjunction with certain ACA market
reform, including guaranteed issue and renewability, nondiscrimination based on health status,
coverage of preexisting health conditions, and rating restrictions (see Table 1). Collectively, these
reforms require insurers to accept all applicants and concurrently restrict insurers’ ability to vary
premiums based on an applicant’s health status and other characteristics. Because these reforms
attempt to provide improved access to coverage for sick individuals or those at high risk of
becoming ill, many argue that a provision such as the individual mandate is necessary to
encourage healthy individuals to participate in the market so insurer risk pools are not limited to
individuals who are high users of health care services (e.g., individuals who have multiple
medical conditions).
Individuals are required to pay a penalty for each month of noncompliance with the mandate
(provided they are not exempt from the mandate). The annual penalty is the greater of a
percentage of “applicable income” 16 or a flat dollar amount assessed on each taxpayer and any
dependents. Table 2 provides the percentage of applicable income and flat dollar penalty amounts
for 2014-2016. After 2016, the penalty will be adjusted for inflation.
Table 2. Individual Mandate Penalty
Percentage of Applicable
Year
Income
Flat Dollar Amount
2014 1.0% $95
2015 2.0% $325
2016 2.5% $695
Source: CRS analysis of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148) and its
implementing regulations.
Notes: Penalty will be adjusted for inflation after 2016. The ACA caps the penalty for noncompliance; the
penalty in any given year cannot exceed the national average premium for bronze-level coverage offered through
exchanges (for the relevant family size).
Taxpayers who are required to pay a penalty but fail to do so will receive a notice from the
Internal Revenue Service (IRS) stating that they owe the penalty. If they still do not pay the
penalty, the IRS can attempt to collect the funds by reducing the amount of the taxpayers’ tax
refund for that year or future years. However, individuals who fail to pay the penalty will not be
subject to any criminal prosecution or penalty for such failure. The Secretary of the Treasury
cannot file notice of lien or a levy on any property for a taxpayer who does not pay the penalty.
15 After 2014, the 8% will be adjusted to reflect the excess rate of premium growth above the rate of income growth for
the period. In 2015, the required contribution for self-only coverage must exceed 8.05% of household income.
16 “Applicable income” is defined as the amount by which an individual’s household income exceeds the applicable
filing threshold for the applicable tax year.
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For more information about the individual mandate, see CRS Report R41331, Individual Mandate
Under ACA.
Exchanges (Marketplaces)
The ACA requires the establishment of a health insurance exchange (marketplace) in every state
as of January 1, 2014. ACA exchanges are marketplaces in which individuals and small
businesses can shop for and purchase private health insurance coverage.17 To facilitate the
purchase of insurance by these groups, the ACA requires the exchanges to have two parts: an
exchange in which individuals can buy nongroup insurance for themselves and their families (an
individual exchange) and a small business health options program (SHOP) exchange that is
designed to assist qualified small employers and their employees with the purchase of insurance.
Exchanges are intended to simplify the experience of providing and obtaining coverage. They are
not intended to supplant the private market outside of exchanges. The ACA requires that plans
offered through an exchange are, for the most part, qualified health plans (QHPs). In general, to
be a QHP, a plan has to offer the EHB package and meet certain standards related to marketing,
choice of providers, and plan networks.18 Each exchange is responsible for certifying the plans it
offers.
Individual Exchange and Financial Assistance
The individual exchange is among the ACA provisions directed at the nongroup market. The ACA
requires that each state establish an individual health insurance exchange. A state may set up its
own exchange or create an exchange in partnership with the federal government. All health plans
available through the nongroup exchanges must meet certain federally required criteria, such as
offering the EHBs.
The open enrollment period for 2015 coverage through the individual exchange is November 15,
2014 to February 15, 2015. Individuals enrolled in a 2014 exchange plan can renew their current
health plan or choose a new health plan through the exchange during the 2015 open enrollment
period. However, if an individual enrolled in a 2014 exchange plan did not make any changes to
his or her coverage by December 15, 2014, that individual was automatically reenrolled in the
same health plan he or she selected in 2014.19
Individuals purchasing nongroup coverage through the exchange may be eligible to receive
financial assistance. Financial assistance for obtaining coverage is based on income and provided
through premium tax credits and cost-sharing subsidies.
17 Individuals who approach exchanges could also potentially be screened for eligibility for public programs such as
Medicaid and the State Children’s Health Insurance Program (CHIP).
18 For more information about the types of plans offered through exchanges, see CRS Report R43233, Private Health
Plans Under the ACA: In Brief.
19 The individual’s coverage will be renewed in the same plan as his or her current plan, unless the current plan is
unavailable. These individuals can also select a plan between December 16, 2014 and February 15, 2015, but the plan
selection will not be effective for January 1, 2015 coverage. For additional information, see 45 C.F.R. § 155.335.
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Premium Tax Credits
Premium tax credits are generally available to individuals who
• are a part of a tax-filing unit;
• purchase nongroup coverage through an exchange;
• have household income20 at or above 100%21 of the federal poverty level (FPL)22
but not more than 400% FPL;23
• are not eligible for minimum essential coverage;24 and
• are U.S. citizens (or legally residing in the United States).
Although the tax credits are generally directed at individuals who do not have access to coverage
outside the nongroup market, certain individuals with access to employer-sponsored insurance
(ESI) may be eligible for premium tax credits. An individual eligible for ESI may still be eligible
for premium credits if the employer’s coverage either is deemed unaffordable25 or does not
provide minimum value.26 If this were the case, the individual could purchase nongroup coverage
through an exchange with the assistance of a premium tax credit.27
The premium credits established under the ACA are advanceable and refundable, meaning tax
filers need not wait until the end of the tax year to benefit from the credit and may claim the full
credit amount even if they have little or no federal income tax liability. The amount of the
premium tax credit varies from person to person. The credit is based on the household income of
the tax filer (and dependents), the premium for the exchange plan in which the tax filer (and
dependents) is enrolled, and other factors.
The amounts received in premium credits are based on the household’s prior year’s income tax
returns or estimates of household income for the current year. These amounts are reconciled in the
next year when individuals file tax returns for the actual year in which they receive premium
credits. If a tax filing unit’s income decreases during the tax year and the filer should have
20 In this instance, household income is modified adjust gross income.
21 Lawfully present immigrants with income below 100% of the federal poverty line (FPL), who are ineligible for
Medicaid for the first five years that they are present in the United States, are also eligible for premium tax credits. For
the purpose of the credits, these individuals will be treated as though their income were exactly 100% FPL.
22 The guidelines that designate the federal poverty level are used in a variety of federal programs for eligibility
purposes. The poverty guidelines vary by family size and by whether the individual resides in the 48 contiguous states
and the District of Columbia, Alaska, or Hawaii. Office of the Assistant Secretary for Planning and Evaluation,
“Frequently Asked Questions Related to the Poverty Guidelines and Poverty,” http://aspe.hhs.gov/Poverty/
faq.cfm#programs.
23 For 2015, the income range corresponding with 100% FPL and 400% FPL is $11,670-$46,680 for a single individual
and $23,850-$95,400 for a family of four. FPL amounts are higher in Alaska and Hawaii.
24 The types of coverage that have been statutorily designated as minimum essential coverage include government-
sponsored programs, employer-sponsored plans, plans in the individual market, and grandfathered health plans. 45
C.F.R. § 156.604.
25 Affordable in this context means the individual’s required contribution toward the plan premium for self-only
coverage does not exceed 9.5% of his or her household income.
26 Minimum value in this context means the plan pays for at least 60%, on average, of covered health care expenses.
27 In this scenario, the individual’s employer could be subject to a penalty. See “Employer Requirements and Penalties
Related to the Offer of Insurance.”
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received a larger tax credit, this additional credit amount will be included in the tax refund for
that year. Any excess amount that was overpaid in premium credits will have to be repaid to the
federal government as a tax payment. The ACA limits the amount of required repayments for
lower-income enrollees. 28
For more detailed information about premium tax credits, see CRS Report R41137, Health
Insurance Premium Credits in the Patient Protection and Affordable Care Act (ACA).
Cost-Sharing Subsidies
Under the ACA, some individuals will also be eligible to receive financial assistance in the form
of cost-sharing subsidies that go toward cost-sharing expenses, such as deductibles, coinsurance,
and co-payments. To be eligible, individuals must be eligible for premium tax credits and enrolled
in a nongroup silver plan through an exchange.29
Cost-sharing assistance is provided in two forms, and both forms are based on income. Some
individuals may receive both types of cost-sharing subsidies if they meet the applicable eligibility
requirements. The first form of cost-sharing assistance reduces the annual out-of-pocket limits for
individuals with income between 100 % FPL and 250% FPL.30 The second form, which also
applies to individuals with income between 100% FPL and 250% FPL, involves reducing eligible
individuals’ cost-sharing requirements to ensure that the plans in which they have enrolled cover
a certain percentage of allowed health care expenses, on average. This form of cost-sharing
assistance directly affects cost-sharing requirements, such as deductibles, coinsurance, and co-
payments.
For more information about the cost-sharing subsidies, see CRS Report R41137, Health
Insurance Premium Credits in the Patient Protection and Affordable Care Act (ACA).
Small Business Health Options Program Exchange
The small business health option program (SHOP) exchanges are among the ACA provisions
directed at the small group market. SHOP exchanges are marketplaces in which private health
insurance issuers sell health insurance plans to small employers. Like the individual exchanges,
all health plans available through SHOP exchanges must meet certain federally required criteria,
such as offering the EHB.
Small employers that offer health insurance coverage to all of their full-time employees are
eligible to use the SHOP exchange.31 Prior to January 1, 2016, the ACA allows states to define a
28 The caps have been modified a few times since the ACA’s enactment. For more information, see CRS Report
R41137, Health Insurance Premium Credits in the Patient Protection and Affordable Care Act (ACA).
29 The ACA establishes different cost-sharing subsidy eligibility criteria for American Indians and Alaskan Natives. For
more information, see CRS Report R41152, Indian Health Care: Impact of the Affordable Care Act (ACA).
30 In 2015, the annual limit is $6,600 for an individual plan and $13,200 for a family plan.
31 An employer’s Small Business Health Options Program (SHOP) exchange eligibility depends on size and whether
the employer offers coverage to all full-time employees. ACA and its implementing regulations set forth methods and
definitions with respect to determining employer size and whether an employee is full time. For more information
about the definitions and methods employers must use to determine size, see CRS Report R43771, Small Business
Health Options Program (SHOP) Exchange.
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small employer as having either 100 or fewer employees or 50 or fewer employees.32 In 2016, all
states must define a small employer as having 100 or fewer employees. In 2017, states will have
the option to allow large employers to use the SHOP exchange.
For more information about the SHOP exchange, see CRS Report R43771, Small Business Health
Options Program (SHOP) Exchange.
Small Business Tax Credit
The ACA includes provisions whereby certain small employers may be eligible for a tax credit,
provided they contribute at least 50% toward their employees’ health insurance premiums. The
small business health insurance tax credit is generally available to qualifying nonprofit and for-
profit employers with fewer than 25 full-time equivalent (FTE) employees with average annual
wages that fall under a statutorily specified cap. 33
Small employers can claim the full credit amount if they meet the following two criteria:
• The employer has 10 or fewer FTEs.
• The employer’s average taxable wages are $25,400 or less in 2014 (adjusted for
inflation in subsequent years). This figure is calculated by dividing the aggregate
amount of wages paid to employees during the year by the number of FTEs (and
then rounding to the nearest $1,000).
In 2014, the credit was phased out as the number of FTEs increased from 10 FTEs to 25 FTEs
and as average employee compensation increased from $25,400 to $50,800.34 The full credit in
2014 covered up to 50% of the for-profit employer’s contribution and 35% of the nonprofit
employer’s contribution. From 2014 onward, the credit is only available to an employer for two
consecutive tax years and to employers who obtain coverage through a SHOP exchange.35
For more information about the small business tax credit, see CRS Report R41158, Summary of
the Small Business Health Insurance Tax Credit Under ACA.
32 According to a March 2014 report published by the Commonwealth Fund, all states chose the 50-employee limit for
2014. See the Commonwealth Fund, Implementing the Affordable Care Act: State Action to Establish SHOP
Marketplaces, March 2014.
33 Full-time equivalent employees (FTEs) are calculated by dividing the total hours worked by all employees during the
tax year by 2,080 (with a maximum of 2,080 hours for any one employee). For calculating the number of FTEs and
their wages, the term employee includes all individuals who are considered employees under the common law standard,
including those who do not work full time. However, the term excludes seasonal workers (persons working no more
than 120 days during the year). In addition, the term excludes self-employed individuals, 2% shareholders in an S-
corporation, 5% owners of an eligible small business, and anyone who is a relation or dependent of these people.
34 The amounts will be adjusted for inflation using the Consumer Price Index-Urban in subsequent years.
35 The Internal Revenue Service (IRS) provides transition relief for certain small employers that cannot obtain a
qualified health plan (QHP) offered through a SHOP exchange because the small employer’s principal business address
is in a county in which a QHP through a SHOP was not available in 2014. The IRS has identified counties in
Washington and Wisconsin to which this transition relief applies. See IRS Notice 2014-6 for more details.
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Employer Requirements and Penalties Related to
the Offer of Insurance
Certain large employers are subject to a shared responsibility provision. This provision does not
explicitly mandate that a large employer offer employees health insurance; instead, it has the
potential to impose penalties on large employers that do not provide affordable and adequate
coverage to their full-time employees (and those employee’s dependents).
The ACA includes an employer penalty that was to be imposed in 2014. However, based on
guidance issued by the IRS, the penalty will not be assessed until 2015. The employer
requirements and penalty is being phased in—the requirement applies to large firms with 100 or
more FTE employees in 2015 and employers with 50 or more FTE employees in 2016.36
A large employer, regardless of the offer of coverage, may be subject to a penalty if any of its
full-time employees37 obtain coverage through an exchange and receive a premium tax credit.
Calculation of the penalty amount depends on whether the employer offers coverage and the total
number of full-time employees working for the employer. Large employers that offer coverage
will only have to pay a penalty if a full-time employee receives a premium tax credit. An
employee will receive a premium tax credit only if his or her self-only coverage from the
employer either exceeds 9.5% of household income or pays for less than 60%, on average, of
covered health care expenses. Large employers that do not offer coverage may be subject to a
penalty only if at least one full-time employee receives a premium tax credit.
No employer may be subject to a penalty based upon health coverage for any part-time employee,
even if the part-time employee receives a premium credit.
For more information, see CRS Report R41159, Potential Employer Penalties Under the Patient
Protection and Affordable Care Act (ACA).
Consumer Operated and Oriented Plan Program
The ACA creates the Consumer Operated and Oriented Plan (CO-OP) program to foster
nonprofit, member-run health insurance companies that would offer qualified health plans in the
nongroup and small group markets. The HHS Secretary is required to use funds appropriated to
the CO-OP program to finance start-up and solvency loans for eligible nonprofit organizations
applying to become CO-OP issuers. Awarded entities are to use the start-up loans for assistance
with costs associated with creating the CO-OP, and the solvency loans must be used to help the
entity meet state solvency requirements.38 All loans must be repaid with interest; the start-up
36 Generally, both full-time and part-time employees are included in the calculation to determine the number of FTEs
the employer has, but the calculation does not include full-time seasonal employees who work for up to 120 days
during the year.
37 Full-time employees are those working 30 hours per week or more.
38 States generally set standards for and monitor state-licensed insurers’ financial operations to ensure that insurers have
adequate reserves to pay policyholders’ claims.
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loans must be repaid within 5 years and the solvency loans must be repaid within 15 years (from
the date of disbursement).
As of the publication date of this report, 23 entities have received loans totaling over $2.1
billion.39 As enacted, the ACA appropriated $6 billion of federal funds for the CO-OP program,
but the American Taxpayer Relief Act of 2012 (ATRA; P.L. 112-240) rescinded most of the
unobligated CO-OP funds. The funds remaining for the program must be used to support the 23
entities that have already received CO-OP loans.40
The entities that have received loans are required to meet certain standards with regard to the
types of health plans they offer. Two-thirds of the plans offered by CO-OP issuers must be QHPs
offered in the nongroup and small group markets; up to one-third of a CO-OP issuer’s plans can
be other types of plans, such as Medicaid managed care plans. With regard to how CO-OP issuers
are expected to interact with exchanges, CO-OP plans must be offered at the silver and gold
levels in the nongroup market in each exchange that serves the geographic regions in which the
CO-OP loan recipient is licensed and intends to provide health care coverage. CO-OP plans must
be offered at both the silver and gold levels in the small group market in each SHOP that serves
the geographic regions in which the entity is offering coverage if the CO-OP loan recipient offers
at least one plan in the small group market outside an exchange.
Multi-State Plan Program
To increase the number of plan choices offered through the exchanges, the ACA directs the Office
of Personnel Management (OPM) to contract with private insurers in each state to offer at least
two41 comprehensive health insurance options, known as multi-state plans (MSPs). Some MSP
options also offer in-network care for out-of-state services, but not all do. Individuals interested in
MSP options would have access to the same financial assistance for premium tax credits and cost-
sharing subsidies as enrollees in other plans.
OPM administers the contracts in a similar manner as the Federal Employee Health Benefits
Program (FEHBP). This includes negotiating plan benefits, monitoring performance, and
overseeing compliance with ACA provisions. MSPs must cover the EHBs and comply with ACA
cost-sharing limits. Carriers must be licensed in each state and comply with state laws. Because
the EHBs differ among states, MSPs can choose to follow a particular state’s EHB package or
one of the three largest by enrollment FEHBP packages.
39 One additional entity, an organization in Vermont, received Consumer Operated and Oriented Plan (CO-OP) loans,
but the Centers for Medicare and Medicaid Services terminated the entity’s loan agreement in 2013. For more
information about the 23 loan recipients, see http://www.cms.gov/CCIIO/Resources/Grants/new-loan-program.html.
40 The Department of Defense and Full-Year Continuing Appropriations Act, 2011 (P.L. 112-10) rescinded $2.2 billion
of the appropriated funding, and the Consolidated Appropriations Act, 2012 (P.L. 112-74) rescinded an additional $400
million from the program. The American Taxpayer Relief Act of 2012 (ATRA; P.L. 112-240) rescinded nearly all other
unobligated CO-OP funds. ATRA directed the Secretary of Health and Human Services (HHS) to create a fund to be
used to support all nonprofit insurance issuers that were awarded CO-OP program loans prior to the date of the law’s
enactment (January 2, 2013). The fund contains 10% of any unobligated CO-OP funds, and the Act rescinded all other
unobligated CO-OP funds.
41 One of the issuers must be nonprofit.
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OPM can contract with a health insurance issuer to offer an MSP if the health insurance issuer
agrees to a phase-in expansion. MSPs would have to be made available in 35 states by 2015, 43
states in 2016 and 2017, and all states by open enrollment in 2017.
In 2014, OPM contracted with the Blue Cross Blue Shield Association to offer over 150 MSPs in
30 states and the District of Columbia. For 2015, OPM has added a second group of insurers, an
association of CO-OP programs, and the MSP program expanded to 5 additional states for a total
of 36 states. The MSP program offers more than 200 plans on the exchanges for 2015.
State Options
Many of the provisions discussed to this point are required to be implemented under ACA.
However, the ACA also includes provisions that states may choose to implement. The flexibility
for states inherent in these state option provisions allows states to continue programs already in
existence or create new programs that may be better-suited to their specific private insurance
markets.
Basic Health Program
The ACA provides states an option to offer coverage to certain low-income individuals through a
basic health program (BHP). Beginning in 2015,42 states are able to establish a BHP, which is a
health insurance program for individuals under the age of 65 who are not eligible for Medicaid or
eligible to enroll in minimum essential coverage. A BHP is offered in lieu of these individuals
obtaining coverage through an exchange. The BHP is available to individuals with household
income between 133% FPL43 and 200% FPL,44 and the BHP coverage must be at least as
comprehensive and affordable as what the individuals could have obtained through an exchange.
A state that chooses to establish a BHP will receive some funds from the federal government to
operate the program.45
As of the publication date of this report, CMS approved MinnesotaCare as the nation’s first BHP,
after Minnesota became the first state to win approval for this option under the ACA.
42 As enacted, the ACA allowed states to establish a Basic Health Program (BHP) beginning in 2014; however, HHS
released guidance stating that the program will not be operational and available as a state option until 2015. For more
information, see Questions and Answers: Medicaid and the Affordable Care Act, available at http://medicaid.gov/State-
Resource-Center/FAQ-Medicaid-and-CHIP-Affordable-Care-Act-ACA-Implementation/Downloads/ACA-FAQ-
BHP.pdf.
43 The ACA includes a five percentage point income disregard, so the effective limit is 138% FPL.
44 The BHP would also be available to individuals who are not citizens of the United States but are lawfully present and
barred from Medicaid because of duration of U.S. residency. These individuals are eligible for a BHP if they otherwise
meet the eligibility criteria and have household income not greater than 138% FPL.
45 The ACA requires the HHS Secretary to transfer funds to a state that establishes a BHP in an amount equal to 95% of
the premium tax credits and the cost-sharing reductions that would have been provided to the state’s BHP enrollees had
they been able to obtain coverage through an exchange.
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Waiver for State Innovation
The ACA allows a state to apply to the HHS Secretary for a waiver of specific requirements with
respect to health insurance coverage within that state for plan years beginning on or after January
1, 2017. The state may apply to waive any or all of the following:
• requirements relating to the establishment of QHPs;
• requirement for the state to have an exchange;
• requirement to offer premium tax credits and cost-sharing reductions through an
exchange;
• requirement for individuals to maintain coverage (individual mandate); and
• penalties imposed on employers whose employees receive premium tax credits.
For a state to obtain a waiver, the HHS Secretary and the Secretary of the Treasury need sufficient
information from the state to determine that its proposed waiver will provide benefits that are at
least as comprehensive as the EHBs; provide coverage and cost-sharing protections against
excessive out-of-pocket spending that are at least as affordable as the cost-sharing provisions in
the ACA; provide coverage to at least a comparable number of residents as the provisions of the
ACA that affect private health insurance would provide; and not increase the federal deficit.
Health Care Choice Compacts
The ACA allows two or more states to create a health care choice compact. The compact would
allow the states to enter into an agreement whereby one or more QHPs could be offered in the
nongroup market in all states in the compact. In this arrangement, a QHP would only be subject to
the laws and regulations of the state in which the plan was issued; however, the issuer of such
QHP would be subject to other rules and requirements (e.g., market conduct rules, consumer
protection rules) imposed by the state(s) in which the consumer resides. Additionally, the issuer
would either be required to be licensed in each state in the compact or to submit to each state’s
standards for offering insurance, and the issuer would have to notify all consumers that it may not
comply with their state’s rules.
A state must have a law that specifically authorizes it to enter into a compact. The HHS Secretary
may approve a compact if the agreement meets certain requirements. The ACA directed the HHS
Secretary to promulgate regulations on this provision no later than July 31, 2013; as of the
publication date of this report, the regulations have not been promulgated. Approved compacts
cannot go into effect before January 1, 2016.
Risk Mitigation Programs
As part of a larger set of private health insurance market reforms, beginning in 2014, the ACA
requires private health insurance issuers to provide coverage to individuals regardless of health
status, medical history, and preexisting conditions. Some individuals are eligible to receive
premium tax credits and cost-sharing subsidies through an exchange (marketplace), which can
increase the attractiveness of coverage by reducing its cost. The individual mandate is also in
effect, which requires most individuals to maintain coverage or otherwise pay a penalty.
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All the new health insurance market reforms and the expanded market of individuals seeking to
purchase insurance contribute to the uncertainty insurers face as they try to price their insurance
products in the first few years of the ACA’s implementation. Additional questions insurers face
include: Will young and healthy uninsured individuals purchase insurance? Have individuals who
were previously uninsured been delaying necessary health care, and how much will their health
care utilization (and costs) change when they have insurance? How many employers will send
their employees to the exchanges to acquire insurance? How will competitors in the market price
their products?
The ACA establishes three programs to help mitigate the financial risk insurers face as a result of
the insurance market reforms. The risk adjustment program is a permanent program that began in
2014 and is intended to mitigate the effects of adverse selection both inside and outside of the
new exchanges. Adverse selection occurs when individuals who expect or plan for high use of
health services enroll in more generous and often more expensive health plans and,
simultaneously, individuals who expect or plan for low use of health services enroll in more
modest plans (both in terms of price and benefits) or choose not to enroll in coverage. Adverse
selection can thus lead to insurers enrolling either a large number of high-cost individuals or a
disproportionate number of low-cost individuals, depending on plan offerings. Risk adjustment is
an adjustment to plan payments to reflect the higher cost of enrolling a relatively sicker group of
enrollees or the lower cost of enrolling a relatively healthier group of enrollees.
The ACA also establishes two temporary programs to help mitigate other types of plan risks. The
reinsurance program is a temporary program (2014-2016) designed to compensate plans for the
cost of individual enrollees who have excessively high medical expenses, such as those who may
have delayed receiving needed health care. The risk corridor program is a temporary program
(2014-2016) designed to mitigate excessive losses (or gains) that result from errors in estimating
premiums as the new market reforms get under way. See Table 3 for more information about the
risk programs.
Table 3. Description of the Patient Protection and Affordable Care Act (ACA) Risk
Mitigation Programs
Reinsurance
Risk
Corridors Risk
Adjustment
Goal
Offset a plan’s risk
Protect against inaccurate
Protect against adverse
associated with high-cost
rate setting.
selection.a
enrol ees.
Objective
Provide funding to plans
Limit the issuers’ losses
Transfer funds from
that incur high costs for
(and gains).
lowest-risk plans to
individual enrollees.
highest-risk plans.
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Reinsurance
Risk
Corridors Risk
Adjustment
Description
Reinsurance typically is
Risk corridors refer to a
Risk adjustment refers to a
thought of as insurance for mechanism that adjusts
mechanism that adjusts
insurers. When issuing
paymentsc to health plans
payments to health plans
policies, an insurer faces
according to a formula
to take into account the
the risk that the
based on each plan’s
risk that each plan is
premiumsb it collects will
actual, allowed expenses in bearing based on its
not be sufficient to cover
relation to a target
enrol ee population. Plans
its expenses and generate
amount. If a plan’s
with enrollment of less-
profit. Reinsurance shifts
expenses exceed a certain
than-average risk will pay
the risk of covering high
percentage above the
an assessment to the state.
expenses from the primary target, the plan’s payment
States will provide
insurer to a reinsurer.
is increased. Likewise, if a
payments to plans with
plan’s expenses are at least higher-than-average risk.
The ACA requires all
a certain percentage below
health insurance issuers
the target, the plan’s
and third-party
payment is decreased.
administrators of group
health plans (including self-
Under the ACA, HHS
insured plans) to
must make payments to a
contribute to a
QHP issuer that
reinsurance program
experiences losses greater
administered by a
than 3% of the issuer’s
nonprofit reinsurance
projections, whereas a
entity. The contribution
QHP issuer whose gains
rate for 2015 is $44 per
are greater than 3% of its
covered life.
projections must remit
payments to HHS.
Non-grandfathered
All QHPs in the individual
All non-grandfathered
individual market plans
and small group markets
individual and small group
(inside and outside of
(inside and outside of
market plans (inside and
exchanges) are eligible for
exchanges) must
outside the exchanges) are
payments from the
participate in the risk
subject to risk adjustment.
reinsurance program.
corridor.
Time Frame
Three years (2014-2016)
Three years (2014-2016)
Permanent; began after
end of benefit year 2014
Source: CRS analysis of the ACA and its implementing regulations.
Notes: HHS = Department of Health and Human Services. QHP = qualified health plan.
a. Adverse selection occurs when individuals who expect or plan for high use of health services tend to enrol
in more generous (and consequently more expensive) health plans.
b. Premiums refer, in general, to payments from an insured individual to the issuer.
c. In this table, payments are between the insurer and HHS Secretary, either to or from.
Author Contact Information
Annie L. Mach
Namrata K. Uberoi
Analyst in Health Care Financing
Analyst in Health Care Financing
amach@crs.loc.gov, 7-7825
nuberoi@crs.loc.gov, 7-0688
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Acknowledgments
Annie Mach, the primary author of this report, is currently away from CRS on extended leave. Please
contact Namrata Uberoi with any questions related to this report.
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