Ensure fair insurance premiums for small groups. There are strict limits on ( Note: The following requirements apply only to BCBS Plans and HMOs):

• How much insurers can charge sicker groups

• Premiums for similar employers can only vary +/- 15% based on all factors
  

• How much insurers can increase an employer's premiums when an employee gets sick
  
  
  

No

No

Ensure access to independent review:

• Consumers can demand independent external review of claims denials

No

Ensure appropriate access to care. Insurers must:

• Cover emergency services that a “prudent layperson” thought necessary
  
  
• Cover transitional care when primary care providers leave network
  
  
• Cover non-formulary prescription drugs in certain situations
  
  
• Allow direct access to OB-GYNs
  
  
  

No

No

No

No

Ensure marketing protections:

• Insurers must follow detailed requirements for marketing materials
  

No

Ensure health plans cover important benefits, such as:

• Mammography screening
  
  
• Minimum mastectomy stays
  
  
• Cervical cancer screening
  
  
• Well-child care
  
  
• Diabetes supplies and education*
  
  
• Prompt payment rules
  
  

No

No

No

No

No

Ensure appropriate oversight of insurers:

• State handles complaints from consumers & providers
  
  
• State investigates, oversees, enforces rules (including financial penalties)
  
  

No

No$

Prevent failures and ensure payment of claims:

• Insurers must maintain financial surpluses that grow with size of insurer
  
  
• State oversees corrective action once insurer nears minimum standards
  
  
• State acts quickly to seize assets to pay claims
  
  

No ($2M cap)

No

No