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1 [1] (September 20, 2018)

handle is hein.crs/crsmthzzbkz0001 and id is 1 raw text is: CRS INSIGHT Consumer Protections in Private Health Insurance for Individuals with Preexisting Health Conditions September 20, 2018 (IN10969) Related Author * Berndtte Fernandez Bernadette Fernandez, Specialist in Health Care Financing (bfernandz bers.loc gov, 7-0322) Individuals with preexisting health conditions may have concerns about-prnd-c in the private health insurance market in which insurers use medical underwriting to assess their risk of offering health insurance to applicants. Before full implementation of the Affordable Care Act's (ACA's; P L 111-148, as amended) insurance reforms, subject to certain exceptions, insurers generally were permitted to consider health factors in determining the offer of insurance, its price, and covered health services. Although references to individuals with preexisting conditions commonly focus on the possibility of denial of insurance, they also pertain to the offer of insurance that is more expensive on the basis of health factors and to insurance that excludes health services to treat preexisting conditions. Current Law Current federal law prohibits those insurer practices from most (but not all) private health plans. Guaranteed issue, adjusted community rating, and coverage ofpreexisting health conditions provide consumer protections related to the offer, price, and scope of insurance, respectively. These provisions are included in the ACA, but their applicability varies across differenttypes of health plans, such as individual vs. group, small group vs. large group, and so on. (The ACA also requires the coverage of essential health benefits in the individual and small-group markets, and the range of covered benefits may be a factor in an individual's decision to purchase insurance. However, this discussion focuses on the key consumer protections that prohibit differentiating individuals with preexisting health conditions from otherwise healthy insurance applicants.) For more information about these and other federal requirements applicable to private plans, see CRS Report R45146, Federal Requirements on Private Health Insurance Plans. Consumer Protections Established Prior to the ACA A number of federal health insurance requirements established prior to the ACA provided protections to individuals with preexisting conditions. Almost all pre-ACA consumer protections applicable to private health insurance were established under the Health Insurance Portability and Accountability Act (HIPAA; P L 104-191). (ACA revisions to HIPAA-established provisions took many forms; HIPAA language was struck and replaced, renumbered, expanded, or left alone.) Specifically, HIPAA's preexisting condition protections applied to the individual health in rance market under limited circumstances and to a greater degree in the groupmarke (see Table 1).

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