Ensure fair insurance premiums for small groups. There are strict limits on:

• How much insurers can charge sicker groups

• Premiums for similar employers can only vary by +/-35% from an average rate (for a class of business) based on health-status or claims experience
  

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

• 15% limit on annual increases for health status, duration, claims experience
  
  

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 “prudentlayperson” thought necessary
  
  
• Cover transitional care from a provider who leaves a network
  
  
• Cover non-formulary prescription drugs in certain situations
  
  
• Offer point-of-service option
  
  
• Allow direct access to OB-GYNs
  
  

No

No

No


No

No

Ensure marketing protections:

• Insurers must follow detailed requirements for marketing materials

Ensure health plans cover important benefits, such as:

• Mammography screening
  
  
• Well-child care
  
  
• Diabetes supplies and education
  
  
• Prompt payment rules
  
  

No

No

No

No (Self-funded AHPs exempt)

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

Promote access for the uninsured:

• Mini-COBRA rules for small employers with fewer than 20 employees
  
  
• Insurers must help fund state high-risk pool

No


No