Insurance

Health Hippo: Insurance

US CODE || CFR || CASES || REPORTS || CONGRESSIONAL RECORD || BILLS || FEDERAL REGISTER

Wherever the art of medicine is loved, there is also a love of humanity.

The Health Insurance Marketplace helps uninsured people find health coverage. By filling out a Marketplace application you’ll find out if you qualify for private health insurance, lower costs based on your household size and income, Medicaid and the Children’s Health Insurance Program (CHIP). If you don’t have coverage, you’ll pay a fee of either 1% of your income, or $95 per adult ($47.50 per child), whichever is higher, on your 2015 income taxes. Some people may qualify for an exemption to the fee, based on income or other factors.

You’re considered covered if you have Medicare, Medicaid, CHIP, any job-based plan, any plan you bought yourself, COBRA, retiree coverage, TRICARE, VA health coverage, or some other kinds of health coverage. You can also buy a plan outside the Marketplace and still be considered covered. If you buy outside the Marketplace, you won’t be eligible for premium tax credits or lower out-of-pocket costs based on your income. If you’re eligible for job-based insurance, you can consider switching to a Marketplace plan, but you won’t qualify for lower costs based on your income unless the job-based insurance isn’t considered affordable or doesn’t meet minimum requirements.

Marketplace Open Enrollment ends on March 31, but you can still buy a Marketplace health plan if you qualify for a special enrollment period. Open Enrollment coverage starts again on November 15. You can apply for Medicaid and CHIP any time.

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U.S. Code

• Affordable Care Act: Insurance Provisions
  • Sec. 1001. Amendments to the Public Health Service Act.
    • No Lifetime or Annual Limits
    • Prohibition on Recessions
    • Coverage of Preventative Health Services
    • Extension of Dependant Coverage
    • Uniform Coverage Explanations
    • Prohibition of Discrimination Based on Salary
    • Ensuring Quality Care
    • Bringing Down the Cost of Care
    • Appeals
  • Sec. 1002. Health insurance consumer information.
  • Sec. 1003. Ensuring that consumers get value for their dollars.
  • Sec. 1004. Effective dates.
  • Sec. 1101. Immediate Access To Insurance For Uninsured Individuals With A Preexisting Condition.
  • Sec. 1102. Reinsurance for early retirees.
  • Sec. 1103. Immediate information that allows consumers to identify affordable coverage options.
  • Sec. 1104. Administrative simplification.
  • Sec. 1105. Effective date.
  • Sec. 1201. Amendment to the Public Health Service Act.
    • Prohibition of Preexisting Condition Exclusions
    • Fair Health Insurance Premiums
    • Guaranteed Availability of Coverage
    • Guaranteed Renewability of Coverage
    • Prohibiting Discrimination Based on Health Status
    • Non-Discrimination in Health Care
    • Comprehensive Covereage
    • Prohibition on Excessive Waiting Periods
  • Sec. 1251. Preservation of right to maintain existing coverage.
  • Sec. 1252. Rating reforms must apply uniformly to all health insurance issuers and group health plans.
  • Sec. 1253. Effective dates.
  • Sec. 1301. Qualified health plan defined.
  • Sec. 1302. Essential health benefits requirements
  • Sec. 1303. Special rules.
  • Sec. 1304. Related definitions.
  • Sec. 1311. Affordable choices of health benefit plans.
  • Sec. 1312. Consumer choice.
  • Sec. 1313. Financial integrity.
  • Sec. 1321. State flexibility in operation and enforcement of Exchanges and related requirements.
  • Sec. 1322. Federal program to assist establishment and operation of nonprofit, member-run health insurance issuers.
  • Sec. 1323. Community health insurance option.
  • Sec. 1324. Level playing field.
  • Sec. 1331. State flexibility to establish basic health programs for low-income individuals not eligible for Medicaid.
  • Sec. 1332. Waiver for State innovation.
  • Sec. 1333. Provisions relating to offering of plans in more than one State.
  • Sec. 1341. Transitional reinsurance program for individual and small group markets in each State.
  • Sec. 1342. Establishment of risk corridors for plans in individual and small group markets.
  • Sec. 1343. Risk adjustment.
  • Sec. 1401. Refundable tax credit providing premium assistance for coverage under a qualified health plan.
  • Sec. 1402. Reduced cost-sharing for individuals enrolling in qualified health plans.
  • Sec. 1411. Procedures for determining eligibility for Exchange participation, premium tax credits and reduced cost-sharing, and individual responsibility exemptions.
  • Sec. 1412. Advance determination and payment of premium tax credits and cost-sharing reductions.
  • Sec. 1413. Streamlining of procedures for enrollment through an exchange and State Medicaid, CHIP, and health subsidy programs.
  • Sec. 1414. Disclosures to carry out eligibility requirements for certain programs.
  • Sec. 1415. Premium tax credit and cost-sharing reduction payments disregarded for Federal and Federally-assisted programs.
  • Sec. 1421. Credit for employee health insurance expenses of small businesses.
  • Sec. 1501. Requirement to maintain minimum essential coverage.
  • Sec. 1502. Reporting of health insurance coverage.
  • Sec. 1511. Automatic enrollment for employees of large employers.
  • Sec. 1512. Employer requirement to inform employees of coverage options.
  • Sec. 1513. Shared responsibility for employers.
  • Sec. 1514. Reporting of employer health insurance coverage.
  • Sec. 1515. Offering of Exchange-participating qualified health plans through cafeteria plans.
  • Sec. 1551. Definitions.
  • Sec. 1552. Transparency in government.
  • Sec. 1553. Prohibition against discrimination on assisted suicide.
  • Sec. 1554. Access to therapies.
  • Sec. 1555. Freedom not to participate in Federal health insurance programs.
  • Sec. 1556. Equity for certain eligible survivors.
  • Sec. 1557. Nondiscrimination.
  • Sec. 1558. Protections for employees.
  • Sec. 1559. Oversight.
  • Sec. 1560. Rules of construction.
  • Sec. 1561. Health information technology enrollment standards and protocols.
  • Sec. 1562. Conforming amendments.
  • Sec. 1563. Sense of the Senate promoting fiscal responsibility.
  • Sec. 3502. Establishing community health teams to support the patient-centered medical home.
  • Sec. 3506. Program to facilitate shared decisionmaking.
  • Sec. 3510. Patient navigator program.
  • Sec. 3602. No cuts in guaranteed benefits.
  • Sec. 4001. National Prevention, Health Promotion and Public Health Council.
  • Sec. 4002. Prevention and Public Health Fund.
  • Sec. 4003. Clinical and community preventive services.
  • Sec. 4004. Education and outreach campaign regarding preventive benefits.
  • Sec. 4102. Oral healthcare prevention activities.
  • Sec. 4201. Community transformation grants.
  • Sec. 4202. Healthy aging, living well; evaluation of community-based prevention and wellness programs for Medicare beneficiaries.
  • Sec. 4203. Removing barriers and improving access to wellness for individuals with disabilities.
  • Sec. 4204. Immunizations.
  • Sec. 4205. Nutrition labeling of standard menu items at chain restaurants.
  • Sec. 4206. Demonstration project concerning individualized wellness plan.
  • Sec. 4207. Reasonable break time for nursing mothers.
  • Sec. 4301. Research on optimizing the delivery of public health services.
  • Sec. 4302. Understanding health disparities: data collection and analysis.
  • Sec. 4303. CDC and employer-based wellness programs.
  • Sec. 4304. Epidemiology-Laboratory Capacity Grants.
  • Sec. 4305. Advancing research and treatment for pain care management.
  • Sec. 4306. Funding for Childhood Obesity Demonstration Project.
  • Sec. 4401. Sense of the Senate concerning CBO scoring.
  • Sec. 4402. Effectiveness of Federal health and wellness initiatives.
  • Sec. 10101. Amendments to subtitle A.
    • No Lifetime Or Annual Limits
    • Provision Of Additional Information
    • Prohibition On Discrimination In Favor Of Highly Compensated Individuals
    • Bringing Down The Cost Of Health Care Coverage
    • Appeals Process
    • Patient Protections
  • Sec. 10102. Amendments to subtitle B.
    • Connecting To Affordable Coverage
  • Sec. 10103. Amendments to subtitle C.
    • Coverage For Individuals Participating In Approved Clinical Trials
    • Annual Report On Self-Insured Plans
    • Study Of Large Group Market
  • Sec. 10104. Amendments to subtitle D.
    • State Opt-out of Abortion Coverage
    • Multi-State Plans
  • Sec. 10105. Amendments to subtitle E.
    • Study Of Geographic Variation In Application Of FPL
  • Sec. 10106. Amendments to subtitle F.
    • Effects On The National Economy And Interstate Commerce
    • Tax Penalties
  • Sec. 10107. Amendments to subtitle G.
    • GAO Study Regarding The Rate Of Denial Of Coverage And Enrollment
    • Small Business Procurement
  • Sec. 10108. Free choice vouchers.
  • Sec. 10109. Development of standards for financial and administrative transactions.
  • Sec. 10201. Amendments to the Social Security Act and title II of this Act.
  • Sec. 10329. Developing methodology to assess health plan value.
  • Sec. 10334. Minority health.
  • Sec. 10401. Amendments to subtitle A.
    • Research, health screenings, and initiatives
  • Sec. 10405. Amendments to subtitle E.
    • Striking section 4401
  • Sec. 10406. Amendment relating to waiving coinsurance for preventive services.
  • Sec. 10407. Better diabetes care.
  • Sec. 10408. Grants for small businesses to provide comprehensive workplace wellness programs.
  • Sec. 10411. Programs relating to congenital heart disease.
  • Sec. 10412. Automated Defibrillation in Adam’s Memory Act.

• Health Insurance Portability and Accountability Act of 1996 (Public Law
  104-191, 104th Congress)

• TITLE I–HEALTH CARE ACCESS, PORTABILITY, AND RENEWABILITY
• TITLE II–PREVENTING HEALTH CARE FRAUD AND ABUSE; ADMINISTRATIVE
  SIMPLIFICATION; MEDICAL LIABILITY REFORM

• TITLE III–TAX-RELATED HEALTH PROVISIONS
• TITLE IV–APPLICATION AND ENFORCEMENT OF GROUP HEALTH PLAN REQUIREMENTS
• TITLE V–REVENUE OFFSETS

• 29 USC CHAPTER 18 (ERISA)
  • 29 USC Sec. 1001 Congressional
    findings and declaration of policy (Sec. 1001a
    Sec.
    1001b)

  • 29 USC Sec. 1002 Definitions
  • 29 USC Sec. 1003 Coverage
  • 29 USC Sec. 1101 Fiduciary
    Responsibilities

  • 29 USC Sec. 1103 Establishment of
    trust

  • 29 USC Sec. 1104 Fiduciary duties
  • 29 USC Sec. 1105 Liability for breach of
    co-fiduciary

  • 29 USC Sec. 1107 Limitation with respect
    to acquisition and holding

  • 29 USC Sec. 1108 Exemptions from
    prohibited transactions

  • 29 USC Sec. 1109 Liability for breach of
    fiduciary duty

  • 29 USC Sec. 1110 Exculpatory provisions;
    insurance

  • 29 USC Sec. 1111 Persons prohibited from
    holding certain positions

  • 29 USC Sec. 1112 Bonding
  • 29 USC Sec. 1113 Limitation of
    actions

  • 29 USC Sec. 1114 Effective date
  • 29 USC Sec. 1131 (Enforcement) Criminal
    penalties

  • 29 USC Sec. 1132 Civil enforcement
  • 29 USC Sec. 1133 Claims procedure
  • 29 USC Sec. 1134 Investigative
    authority

  • 29 USC Sec. 1135 Regulations
  • 29 USC Sec. 1136 Coordination and
    responsibility of agencies

  • 29 USC Sec. 1137 Administration
  • 29 USC Sec. 1138 Appropriations
  • 29 USC Sec. 1139 Separability
  • 29 USC Sec. 1140 Interference with
    protected rights

  • 29 USC Sec. 1142 Advisory Council on
    Employee Welfare and Pension Benefit

  • 29 USC Sec. 1143 Research, studies, and
    reports

  • 29 USC Sec. 1144 Other laws
  • 29 USC Sec. 1145 Delinquent
    contributions

  • 29 USC Sec. 1161 (Group health plans)
    Plans must provide continuation coverage

  • 29 USC Sec. 1162 Continuation
    coverage

  • 29 USC Sec. 1163 Qualifying event
  • 29 USC Sec. 1164 Applicable premium
  • 29 USC Sec. 1165 Election
  • 29 USC Sec. 1166 Notice requirements
  • 29 USC Sec. 1167 Definitions and special
    rules

  • 29 USC Sec. 1168 Regulations
  • 29 USC Sec. 1169 Additional standards
    for group health plans
  • 42 USC Sec.
    1395ss Certification of Medicare supplemental health plans (Medigap)

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Code of Federal
Regulations

• 5 CFR PART 890 – FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM (890.101 to 890.1210)
  • 5 CFR
    Sec. 890.201 Minimum standards for health benefits plans.

  • 5 CFR
    Sec. 890.202 Minimum standards for health benefits carriers.

  • 5 CFR
    Sec. 890.203 Application for approval of, and proposal of amendments to, health benefit plans.

  • 5 CFR
    Sec. 890.204 Withdrawal of approval of health benefits plans.

  • 5 CFR
    Sec. 890.205 Nonrenewal of contracts of health benefits plans.

• 29 CFR CHAPTER XXV – EMPLOYEE BENEFITS SECURITY ADMINISTRATION, DEPARTMENT OF LABOR
  • SUBCHAPTER A GENERAL (Part 2509 INTERPRETIVE BULLETINS RELATING TO ERISA)
    • Sec. 2509.75-2 Interpretive bulletin relating to prohibited transactions.
    • Sec. 2509.75-3 Interpretive bulletin relating to investments by employee benefit plans in securities of registered investment companies.
    • Sec. 2509.75-4 Interpretive bulletin relating to indemnification of fiduciaries.
    • Sec. 2509.75-5 Questions and answers relating to fiduciary responsibility.
    • Sec. 2509.75-6 Interpretive bulletin relating to section 408(c)(2) of the Employee Retirement Income Security Act of 1974.
    • Sec. 2509.75-8 Questions and answers relating to fiduciary responsibility under the Employee Retirement Income Security Act of 1974.
    • Sec. 2509.75-9 Interpretive bulletin relating to guidelines on independence of accountant retained by Employee Benefit Plan.
    • Sec. 2509.75-10 Interpretive bulletin relating to the ERISA Guidelines and the Special Reliance Procedure.
    • Sec. 2509.78-1 Interpretive bulletin relating to payments by certain employee welfare benefit plans.
    • Sec. 2509.94-3 Interpretive bulletin relating to in-kind contributions to employee benefit plans.
    • Sec. 2509.95-1 Interpretive bulletin relating to the fiduciary standards under ERISA when selecting an annuity provider for a defined benefit pension plan.
    • Sec. 2509.99-1 Interpretive Bulletin Relating to Payroll Deduction IRAs.
  • SUBCHAPTER B DEFINITIONS AND COVERAGE UNDER THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974 (Part 2510)
  • SUBCHAPTER C REPORTING AND DISCLOSURE UNDER THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974 (Part 2520)
  • SUBCHAPTER D MINIMUM STANDARDS FOR EMPLOYEE PENSION BENEFIT PLANS UNDER THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974 (Part 2530)
  • SUBCHAPTER E [Reserved]
  • SUBCHAPTER F FIDUCIARY RESPONSIBILITY UNDER THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974 (Part 2550)
  • SUBCHAPTER G ADMINISTRATION AND ENFORCEMENT UNDER THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974 (Parts 2560 to 2578)
  • SUBCHAPTER H [Reserved]
  • SUBCHAPTER I TEMPORARY BONDING RULES UNDER THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974 (Part 2580)
  • SUBCHAPTER J FIDUCIARY RESPONSIBILITY UNDER THE FEDERAL EMPLOYEES’ RETIREMENT SYSTEM ACT OF 1986 (Parts 2582 to 2584)
  • SUBCHAPTER K ADMINISTRATION AND ENFORCEMENT UNDER THE FEDERAL EMPLOYEES’ RETIREMENT SYSTEM ACT OF 1986 (Part 2589)
  • SUBCHAPTER L GROUP HEALTH PLANS (Part 2590)
    • SUBPART A Continuation Coverage, Qualified Medical Child Support Orders, Coverage for Adopted Children (2590.606-1 – 2590.609-2)
    • SUBPART B Health Coverage Portability, Nondiscrimination, and Renewability (2590.701-1 – 2590.703)
      • Sec. 2590.701-1 Basis and scope.
      • Sec. 2590.701-2 Definitions.
      • Sec. 2590.701-3 Limitations on preexisting condition exclusion period.
      • Sec. 2590.701-4 Rules relating to creditable coverage.
      • Sec. 2590.701-5 Evidence of creditable coverage.
      • Sec. 2590.701-6 Special enrollment periods.
      • Sec. 2590.701-7 HMO affiliation period as an alternative to a preexisting condition exclusion.
      • Sec. 2590.701-8 Interaction With the Family and Medical Leave Act [Reserved]
      • Sec. 2590.702 Prohibiting discrimination against participants and beneficiaries based on a health factor.
      • Sec. 2590.702-1 Additional requirements prohibiting discrimination based on genetic information.
    • SUBPART C Other Requirements (2590.711 – 2590.715-2719A)
      • Sec. 2590.711 Standards relating to benefits for mothers and newborns.
      • Sec. 2590.712 Parity in mental health and substance use disorder benefits.
      • Sec. 2590.715-1251 Preservation of right to maintain existing coverage.
      • Sec. 2590.715-2704 Prohibition of preexisting condition exclusions.
      • Sec. 2590.715-2711 No lifetime or annual limits.
      • Sec. 2590.715-2712 Rules regarding rescissions.
      • Sec. 2590.715-2713 Coverage of preventive health services.
      • Sec. 2590.715-2714 Eligibliity of chlidren until at least age 26.
      • Sec. 2590.715-2715 Summary of benefits and coverage and uniform glossary.
      • Sec. 2590.715-2719 Internal claims and appeals and external review processes.
      • Sec. 2590.715-2719A Patient protections.

• 32 CFR Part 199 CIVILIAN HEALTH AND MEDICAL PROGRAM OF THE UNIFORMED SERVICES (CHAMPUS & TRICARE)
  • Sec. 199.1 General provisions.
  • Sec. 199.2 Definitions.
  • Sec. 199.3 Eligibility.
  • Sec. 199.4 Basic program benefits.
  • Sec. 199.5 TRICARE Extended Care Health Option (ECHO).
  • Sec. 199.6 TRICARE—authorized providers.
  • Sec. 199.7 Claims submission, review, and payment.
  • Sec. 199.8 Double coverage.
  • Sec. 199.9 Administrative remedies for fraud, abuse, and conflict of interest.
  • Sec. 199.10 Appeal and hearing procedures.
  • Sec. 199.11 Overpayments recovery.
  • Sec. 199.12 Third party recoveries.
  • Sec. 199.13 TRICARE Dental Program.
  • Sec. 199.14 Provider reimbursement methods.
  • Sec. 199.15 Quality and utilization review peer review organization program.
  • Sec. 199.16 Supplemental Health Care Program for active duty members.
  • Sec. 199.17 TRICARE program.
  • Sec. 199.18 Uniform HMO Benefit.
  • Sec. 199.20 Continued Health Care Benefit Program (CHCBP).
  • Sec. 199.21 Pharmacy benefits program.
  • Sec. 199.22 TRICARE Retiree Dental Program (TRDP).
  • Sec. 199.23 Special Supplemental Food Program.
  • Sec. 199.24 TRICARE Reserve Select.
  • Sec. 199.25 TRICARE Retired Reserve.
  • Sec. 199.26 TRICARE Young Adult.
  • Appendix A Acronyms

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Cases

• CIGNA Corp. v. Amara (U.S. 2010)(ERISA did not give the district court authority to reform CIGNA’s plan as relief was authorized by section which allowed a participant, beneficiary, or fiduciary “to obtain other appropriate relief” to redress violations of ERISA “or the [plan’s] terms.” Because ERISA authorized “appropriate equitable relief” for violations, the relevant standard of harm would depend on the equitable theory by which the district court provided relief.
• Curtiss-Wright Corp. v.
  Schoonejongen (U.S. 1995) (standard provision in many employer-provided benefit plans
  stating that company reserves the right at any time to amend the plan- sets forth an amendment
  procedure that satisfies ERISA requirements)

• New York State Conference of Blue
  Cross & Blue Shield Plans v. Travelers Ins. Co. (U.S. 1995)
  (surcharges that indirectly impact ERISA plans not preempted)

• Safeco Life Ins.
  Co. v. Musser (7th Cir. 1995) (Wisconsin fees on health insurers to subsidize health
  care for the poor not preempted by ERISA)

• Varity Corporation v. Howe (U.S. 1996) (Varity and Massey-Ferguson, acting as ERISA fiduciaries, harmed plan beneficiaries
  through deliberate deception violating ERISA’s 404(a)’s fiduciary obligation)

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Reports

• Early Effects of Medical Loss Ratio Requirements and Rebates on Insurers and Enrollees GAO-14-580: Jul 10, 2014. The Patient Protection and Affordable Care Act (PPACA) established federal minimum medical loss ratio (MLR) standards for the percentage of premiums private insurers must spend on their enrollees’ medical care claims and activities to improve health care quality, as opposed to what they spend on administrative (“non-claims”) costs. Insurers report to the Centers for Medicare & Medicaid Services (CMS) annually on their PPACA MLRs. All eight insurers reported that they increased their premium rates since 2011 and that they based these decisions on a variety of factors, such as trends in medical care claims, competition with other insurers, and other requirements. Three of the eight insurers stated that the MLR requirements were one among several factors that influenced their decisions about premium rates.
• Challenges for Those Claiming Social Security Benefits Early and New Health Coverage Options GAO-14-311. Published: Apr 23, 2014. GAO estimates that nearly a million early claimers did not have government or employer-sponsored health insurance before 2014. Of these, 14 percent may be newly eligible for Medicaid in 2014 due to expansion in 25 states and the District of Columbia and 58 percent could be eligible for tax credits that reduce the premiums for coverage purchased through the new health insurance exchanges. However, GAO estimates that 10 percent of these early claimers had incomes below the federal poverty level but lived in states that did not expand Medicaid and had incomes too low for federal exchange tax credits.
• Health Insurance: Seven States’ Actions to Establish Exchanges under the Patient Protection and Affordable Care Act GAO-13-486: Apr 30, 2013. Despite some challenges, the seven selected states in GAO’s review reported they have taken actions to create exchanges, which they expect will be ready for enrollment by the deadline of October 1, 2013.
• Medicaid Expansion:States’ Implementation of the Patient Protection and Affordable Care Act GAO-12-821: Aug 1, 2012. In terms of states’ views on the fiscal implications of the Medicaid expansion on states’ budget planning, our survey found that across fiscal years 2012 to 2020, the majority of state budget directors believe that three aspects of Medicaid expansion will contribute to costs: (1) the administration for managing Medicaid enrollment, (2) the acquisition or modification of information technology systems to support Medicaid, and (3) enrolling previously eligible but not enrolled individuals in Medicaid.
• Patient Protection and Affordable Care Act: IRS Managing Implementation Risks, but Its Approach Could Be Refined GAO-12-690: Jun 13, 2012. GAO did not find evidence that a risk plan was used to track and mitigate risks when coordinating with partner agencies, such as the Department of Health and Human Services. Without a system for tracking shared risks, IRS is more likely to overlook risks or duplicate efforts.
• Causes of Action under the Patient Protection and Affordable Care Act B-322525, Mar 23, 2012. We do not believe that the implementation of the provisions identified in section 3512 of PPACA, including the development, recognition, or implementation of related guidelines and standards, is likely to give rise to new causes of action or claims. Ultimately, the courts will determine, in the context of specific litigation, whether the PPACA provisions identified in section 3512 give rise to new causes of action or claims.
• Patient Protection and Affordable Care Act: HHS’s Process for Awarding and Overseeing Exchange and Rate Review Grants to States GAO-13-543: May 31, 2013. The grant award process consists of a series of steps during which the agency solicits, screens, and evaluates grant applications, and then makes funding awards. Once HHS deems that applications meet program eligibility criteria, applications go through various reviews, including a review by independent experts and HHS officials. On the basis of these reviews, HHS determines whether states’ proposed activities are allowable, and if so, whether the associated requests for grant funding are reasonable.
• Patient Protection and Affordable Care Act: Status of CMS Efforts to Establish Federally Facilitated Health Insurance Exchanges GAO-13-601: Jun 19, 2013. CMS recently completed risk assessments and plans for mitigating risks associated with the data hub, and is also working on strategies to address state preparedness contingencies. Whether these efforts will assure the timely and smooth implementation of the exchanges by October 2013 cannot yet be determined.
• Patient Protection and Affordable Care Act: Status of Federal and State Efforts to Establish Health Insurance Exchanges for Small Businesses GAO-13-614: Jun 19, 2013. Of the 33 states with FF-SHOPs and 34 states with FFEs, 15 states are expected to assist CMS to carry out certain functions of the exchange. However, the activities that CMS plans to complete in these 15 exchanges have evolved, and CMS activities in these and other exchanges may continue to change.
• Patient Protection and Affordable Care Act: IRS Should Expand Its Strategic Approach to Implementation GAO-11-719: Jun 29, 2011. The report (1) describes IRS’s PPACA responsibilities and effective dates and (2) assesses the extent to which IRS, in planning PPACA implementation, is following leading practices in four areas–developing an overall management structure (including goals and performance measures), estimating and tracking costs, assuring compliance with the new law while minimizing burden, and managing risk.
• Patient Protection and Affordable Care Act: Effect on Long-Term Federal Budget Outlook Largely Depends on Whether Cost Containment Sustained GAO-13-281: Jan 31, 2013. Federal health care spending is expected to continue growing faster than the economy. In the near term, this is driven by increasing enrollment in federal health care programs due to the aging of the population and expanded eligibility.
• Office of Personnel Management; Patient Protection and Affordable Care Act; Establishment of the Multi-State Plan Program for the Affordable Insurance Exchanges GAO-13-507R, Apr 1, 2013. Through contracts with OPM, health insurance issuers will offer at least two multi-state plans (MSPs) on each of the Affordable Insurance Exchanges. One of the issuers must be non-profit.
• Patient Protection and Affordable Care Act: Estimates of the Effect on the Prevalence of Employer-Sponsored Health Coverage GAO-12-768: Jul 13, 2012. The five studies GAO reviewed that used microsimulation models to estimate the effects of the Patient Protection and Affordable Care Act (PPACA) on employer-sponsored coverage generally predicted little change in prevalence in the near term, while results of employer surveys varied more widely.
• Health Care: Survey on States’ Implementation of the Patient Protection and Affordable Care Act GAO-12-944SP: Aug 1, 2012. This e-supplement presents the questions and aggregate results from a Web survey of state budget directors on the fiscal implications of Medicaid expansion implementation on state budget planning.
• Health Care Coverage: Job Lock and the Potential Impact of the Patient Protection and Affordable Care Act GAO-12-166R: Dec 15, 2011. Empirical research generally indicates that certain types of workers are more likely to remain in jobs they would otherwise leave in order to keep their employer-sponsored health care coverage.
• Patient Protection and Affordable Care Act: Status of CMS Efforts to Establish Federally Facilitated Health Care Exchanges and the Federal Data Services Hub GAO-13-786T: Jul 17, 2013. n brief, GAO’s work found that CMS will operate a health insurance exchange in the 34 states that will not operate a state-based exchange for 2014. While CMS will retain full authority over each of these 34 FFEs, it planned to allow 15 of these states to assist it in carrying out certain FFE functions. To support consumer-eligibility determinations, CMS is developing a data hub that will provide electronic, near real-time access to federal data, as well as provide access to state and third-party data sources needed to verify consumer-eligibility information.
• Private Pensions: Clarity of Required Reports and Disclosures
  Could Be Improved GAO-14-92: Published: Nov 21, 2013. Sponsors of private sector pension plans are required to
  submit various reports to federal agencies and disclosures to participants depending on the plans’ type, size, and
  circumstances. GAO identified more than 130 reports and disclosures stemming from provisions of the Employee
  Retirement Income Security Act of 1974, as amended (ERISA), and the Internal Revenue Code, as administered largely
  by three ERISA agencies: the Department of Labor (Labor), Internal Revenue Service (IRS), and Pension Benefit
  Guaranty Corporation (PBGC).
• Private Pensions: Revised Electronic Disclosure Rules Could
  Clarify Use and Better Protect Participant Choice GAO-13-594: Published: Sep 13, 2013. GAO found that, although
  participants may request paper disclosures at any time, requirements permitting default electronic delivery and
  sponsors’ use of a secured website to furnish disclosures may not fully protect a participant’s ability to choose
  paper as their preferred delivery method on an ongoing, rather than a document-by-document, basis.
• Private Pensions: Timely Action Needed to Address Impending
  Multiemployer Plan Insolvencies GAO-13-240: Published: Mar 28, 2013. A survey conducted by a large actuarial and
  consulting firm serving multiemployer plans suggests that the large majority of the most severely underfunded
  plans–those designated as being in critical status–either have increased or will increase employer contributions
  or reduce participant benefits.
• HHS Research Awards: Use of Recovery Act and Patient Protection and Affordable Care Act Funds for Comparative Effectiveness Research GAO-11-712R: Jun 14, 2011. Comparative effectiveness research (CER) is research comparing different interventions and strategies to prevent, diagnose, treat, and monitor health conditions.
• Patient Protection and Affordable Care Act: Enrollment and Spending in the Early Retiree Reinsurance and Pre-existing Condition Insurance Plan Programs GAO-13-391: Apr 30, 2013. The Center for Consumer Information and Insurance Oversight (CCIIO) discontinued enrollment in the Early Retiree Reinsurance Program (ERRP) in early 2011 and stopped most program reimbursements the following year to keep spending within the $5 billion ERRP appropriation. Enrollment and spending for the Pre-existing Condition Insurance Plan (PCIP) program have grown substantially.
• Patient Protection and Affordable Care Act; Establishment of Consumer Operated and Oriented Plan (CO-OP) Program. GAO-12-334R, Dec 22, 2011.
• Health Insurance Issuers Implementing Medical Loss Ratio (MLR) Requirements Under the Patient Protection and Affordable Care Act GAO-11-259R, Dec 15, 2010. HHS complied with applicable requirements in promulgating the rule.
• Patient Protection and Affordable Care Act: Contracts Awarded and Consultants Retained by Federal Departments and Agencies to Assist in Implementing the Act GAO-11-797R: Jul 14, 2011. This report provides information on contracts awarded by the Department of Health and Human Services (HHS) and other federal departments and agencies related to authority provided by PPACA, including information on firms retained to facilitate contracting and consultants retained by HHS and other federal departments and agencies to assist in PPACA implementation.
• Medicaid Outpatient Prescription Drugs: Estimated Changes to Federal Upper Limits Using the Formula under the Patient Protection and Affordable Care Act GAO-11-141R: Dec 15, 2010. Spending on prescription drugs in Medicaid–the joint federal-state program that finances medical services for certain low-income adults and children–totaled $15.2 billion in fiscal year 2008. State Medicaid programs do not directly purchase prescription drugs; instead, they reimburse retail pharmacies for covered prescription drugs dispensed to Medicaid beneficiaries.
• Enforcement Improvements Made but Additional Actions Could
  Further Enhance Pension Plan Oversight GAO-07-22: Published: Jan 18, 2007. The Senate Committee on Health,
  Education, Labor and Pensions asked GAO to review EBSA’s enforcement program. Specifically, this report assesses (1)
  the extent to which EBSA has improved its compliance activities since 2002; (2) how EBSA’s enforcement practices
  compare to those of other agencies; and (3) what obstacles, if any, affect ERISA enforcement.

• ERISA’s Effect on Remedies for Benefit Denials and Medical
  Malpractice HEHS-98-154, Jul 13, 1998. GAO reviewed how people enrolled in employer-based managed care plans are
  compensated when they are improperly denied health care benefits or when they experience negligent medical care and
  the role that the Employee Retirement Income Security Act (ERISA) plays.

• Retiree Health
  Insurance: Erosion in Retiree Health Benefits Offered by Large Employers. T-HEHS-98-110. 12 pp. March 10, 1998.
  Discusses the erosion in employer-based health benefits for retirees, especially early retirees, focusing on: (1)
  trends in access to employer-sponsored retiree health benefits; (2) the impact on retirees of an employer’s decision
  to terminate health benefits; and (3) federal safeguards that protect the rights of retirees who have health
  benefits.

• Medigap Insurance:
  Compliance With Federal Standards Has Increased. HEHS-98-66. 13 pp. plus 7 appendices (23 pp.) March 6, 1998.
  Reviews insurers’ compliance with Medigap loss ratios and standards, focusing on: (1) the overall Medigap market;
  (2) which Medigap policies had loss ratios below the standards in 1994 and 1995; and (3) which policies resulted in
  refunds or credits, or, if not, why.

• Health Insurance
  Standards: New Federal Law Creates Challenges for Consumers, Insurers, Regulators. HEHS-98-67. 30 pp. plus 6
  appendices (18 pp.) February 25, 1998. Reviews the implementation of the Health Insurance Portability and
  Accountability Act (HIPAA), focusing on issues affecting: (1) consumers; (2) issuers of health coverage, including
  employers and insurance carriers; (3) state insurance regulators; and (4) federal regulators.

• Medical Savings
  Accounts: Findings From Insurer Survey. HEHS-98-57. December 19, 1997. Pursuant to a legislative requirement,
  GAO competitively awarded four contracts to study Medical Savings Accounts (MSA), including consumer choice and the
  scope of high-deductible plans purchased in conjunction with MSAs.

• Health Insurance:
  Coverage Leads to Increased Health Care Access for Children. HEHS-98-14. 27 pp. plus 2 enclosures (13 pp.)
  November 24, 1997. Reports on the relationship between health insurance and health care access, focusing on: (1)
  what effect health insurance has on children’s access to health care; (2) whether expanding publicly funded
  insurance improves their access; and (3) barriers besides lack of insurance that might deter children from getting
  health care.

• Health Insurance:
  Management Strategies Used by Large Employers to Control Costs (Chapter Report, 05/06/97, GAO/HEHS-97-71).
  Pursuant to a congressional request, GAO reviewed the strategies of large, innovative purchasers who have attempted
  to stem the rapid escalation in health insurance costs while maintaining or enhancing the quality of care for their
  employees.

• Medigap Insurance: Insurers’ Compliance With Federal Minimum Loss Ratio Standards, 1988-91 (GAO 1994) From 1988 through 1991, the market for Medicare supplemental insurance–commonly called Medigap–grew by more than 50 percent; premiums rose from about $7 billion to $11 billion.
• Health Insurance:
  How Health Care Reform May Affect State Regulation (Testimony, 11/05/93, GAO/T-HRD-94-55). Most health care
  reform proposals before Congress expect the states to implement and enforce new requirements on private health
  insurers–a responsibility that may require states to undertake new regulatory tasks and regulate new organizations.

• Health Insurance
  Portability: Reform Could Ensure Continued Coverage for Up to 25 Million Americans (Letter Report, 09/19/95,
  GAO/HEHS-95-257). Pursuant to a congressional request, GAO provided information on: (1) the protections offered by
  current state and federal health insurance portability reforms; (2) the number of people who could be affected by
  broader national portability standards; and (3) other issues related to the design of national portability
  standards.

• Health Insurance
  Regulation: Variation in Recent State Small Employer Health Insurance Reforms (Fact Sheet, 06/12/95,
  GAO/HEHS-95-161FS). Pursuant to a congressional request, GAO provided information on state legislation to improve
  portability, access, and rating practices for the small-employer and individual health insurance markets.

• Access to Health
  Insurance: Public and Private Employers’ Experience With Purchasing Cooperatives (Letter Report, 05/31/94,
  GAO/HEHS-94-142). One of the few areas of widespread agreement in the health care debate is that small businesses
  and other small organizations have a tough time buying and keeping health insurance for their employees.

• Medicare/ Medicaid:
  Data Bank Unlikely to Increase Collections From Other Insurers (GAO 1994) The
  Department of Health and Human Services has been directed to establish a data bank, beginning in February 1995, that
  would contain information on all workers, spouses, and dependents who are covered by employer-provided health
  insurance.

• Health Insurance for
  the Elderly: Owning Duplicate Policies Is Costly and Unnecessary (GAO 1994)
  Owning multiple health insurance policies to supplement Medicare is both costly and unnecessary. GAO estimated that
  about 3 million elderly Medicare beneficiaries paid about $1.8 billion in 1991 for policies that probably involved
  duplicate coverage.

• Medigap Insurance:
  Insurers’ Compliance with Federal Minimum Loss Ratio Standards, 1988-93 (GAO 1995) Pursuant to a congressional request, GAO reviewed benefit payments by Medigap policies between
  1988 and 1994, focusing on trends in Medigap insurers’ aggregate loss ratio performance.

• Private Health
  Insurance: Millions Relying on Individual Market Face Cost and Coverage Tradeoffs (GAO 1996) Pursuant to a congressional request, GAO provided information on the private individual health
  insurance market.

• Medigap Insurance:
  Alternatives for Medicare Beneficiaries to Avoid Medical Underwriting (GAO 1996) Pursuant to a legislative requirement, GAO reviewed Medigap policies, focusing on: (1) the extent
  to which Medicare beneficiaries are subject to medical underwriting when they change Medigap policies; and (2)
  options for modifying federal Medigap requirements to ensure that medical underwriting is not a problem in such
  cases.

• Employment- Based
  Health Insurance: Costs Increase and Family Coverage Decreases (GAO 1997)
  Pursuant to a congressional request, GAO provided information on the decline in employment-based health insurance.

• Medigap Insurance:
  Alternatives for Medicare Beneficiaries to Avoid Medical Underwriting (GAO 1996) Pursuant to a legislative requirement, GAO reviewed Medigap policies, focusing on: (1) the extent
  to which Medicare beneficiaries are subject to medical underwriting when they change Medigap policies; and (2)
  options for modifying federal Medigap requirements to ensure that medical underwriting is not a problem in such
  cases.

• Health Insurance:
  Coverage of Autologous Bone Marrow Transplantation for Breast Cancer (GAO 1996)
  Although many insurers now cover the cost of autologous bone marrow transplantation, a new and expensive treatment
  for breast cancer, issues surrounding the procedure have put several goals of the U.S. health care systems in
  conflict: access to the best, most advanced care; cost containment; and research adequate to assess the value of new
  treatments.

• Health Insurance:
  Management Strategies Used by Large Employers to Control Costs (GAO 1997)
  Pursuant to a congressional request, GAO reviewed the strategies of large, innovative purchasers who have attempted
  to stem the rapid escalation in health insurance costs while maintaining or enhancing the quality of care for their
  employees.

• Health Care
  Alliances: Issues Relating To Geographic Boundaries (GAO 1994) A common feature
  of many health reform bills is the creation of public or private health purchasing groups, known as alliances.

• Private Health
  Insurance: Millions Relying on Individual Market Face Cost and Coverage Tradeoffs (GAO 1996) Pursuant to a congressional request, GAO provided information on the private individual health
  insurance market.

• Tax Policy: Health
  Insurance Tax Credit Participation Rate Was Low (GAO 1994) This report provides
  information on the health insurance tax credit, which was established to encourage low-income workers to buy private
  health insurance for their families.

• Health Insurance:
  California Public Employees’ Alliance Has Reduced Recent Premium Growth (GAO 1993) As part of the ongoing debate over health care reform, policy makers have been weighing the pros and
  cons of alternative ways to purchase care.

• Health Care Reform:
  Proposals Have Potential to Reduce Administrative Costs (GAO 1994) Americans
  today receive health insurance from a multitude of sources, including more than 1,200 commercial insurers; 550
  health maintenance organizations; 69 Blue Cross and Blue Shield plans; thousands of self-insured plans run by
  private employers; and government programs, such as Medicaid and Medicare.

• Health Insurance
  Regulation: Varying State Requirements Affect Cost of Insurance (GAO 1996) Focusing on: (1)
  premium taxes on insured health plans; (2) mandated health benefits; (3) financial solvency standards; and (4) state
  health insurance reforms affecting small employers.

• Cost of Health Care Task Force Related Activities
  (GAO 1995) In January 1993, President Clinton established a task force on health care
  reform.

• Health Care Reform:
  “Report Cards” Are Useful but Significant Issues Need to Be Addressed (GAO 1994) As part of the debate over health care reform, Congress is considering requiring health plans to
  provide prospective purchasers with information on the quality of care they furnish.

• Health Care Reform:
  Considerations for Risk Adjustment Under Community Rating (GAO 1994) As part of
  the debate over health care reform, some have proposed prohibiting insurers from denying coverage or charging
  different premiums to persons on the basis of their health status.

• Small Business:
  SBA’s Health Care Reform Activities (GAO 1994) In late September 1993,
  anticipating strong interest in the administration’s health care reform proposal, the Small Business Administration
  (SBA) and the Commerce Department jointly produced a brochure describing how health insurance would be provided and
  what role small employers would play in financing insurance for their workers under the proposed Health Security
  Act.

• Health Care in
  Hawaii: Implications for National Reform (GAO 1994) For nearly 20, years, Hawaii
  has been a leader in the effort to achieve universal access to health insurance.

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