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September 1: Health insurance rates get stricter scrutiny

Affordable Care Act requires closer review of rate hikes over 10% for individual and small group health plans

August 31, 2011


New Affordable Care Act Insurance Rate Review Rules Start September 1


Health Insurance Rates Will Face Stricter Scrutiny Nationwide; CMS Will Review Rates for 9 States With Inadequate Oversight

WASHINGTON, D.C. – Starting September 1, health insurance rates for the individual and small group markets will face stricter scrutiny to determine whether they are reasonable under new rules required by the Affordable Care Act. The Centers for Medicare and Medicaid Services (CMS) will review rates in eight states that lack the authority to adequately review rates for one or both markets. The remaining 42 states will conduct their own reviews.

“These new rules combined with the funding states are receiving under the Affordable Care Act will trigger much closer scrutiny of health insurance rate hikes,” said DeAnn Friedholm, the director of Consumers Union’s health reform campaign. “But ultimately, it will be up to the states to protect consumers when rate increases are found to be unreasonable. States need to make sure they have the tools necessary to prevent unreasonable rate increases from going into effect. And some states that have the authority to curb rate hikes need to act more aggressively to prevent insurers from gouging consumers.”

Starting September 1, rate increases higher than 10 percent will be reviewed by states with rate review procedures meeting certain standards and by CMS for states that do not have such standards. CMS will conduct rate review covering both the individual and small group markets in Alabama, Arizona, Louisiana, Missouri, Montana and Wyoming. It will conduct small-group market reviews in Pennsylvania and Virginia.

Insurers will have to submit a “justification” for an increase of 10 percent or more to CMS and state regulators prior to implementing the rate hike. CMS will post such justifications on its website. Insurers will be required to post a justification on their websites for rate hikes that are determined to be unreasonable.

Under the Affordable Care Act, the power to deny or modify each proposed rate increase remains with the states. But not all states have the power to prevent unreasonable rate increases from going into effect or have regulators who exercise this authority. Some state regulators closely examine proposed rate increases and insurers’ justifications, but other states have little capability to do so. In most states, consumers do not receive adequate information about rate increases and are not able to participate in the review process through hearings or other public forums. Most states have received federal grant funds to improve their rate review process.

Consumers Union has developed a state model rate review law for individual market plans and is working to encourage states to adopt reforms that ensure greater oversight, transparency and insurance company accountability.

Michael McCauley (mccami@consumer.org) 415-431-6747, ext 126