Private Health Insurance: Waivers of Restrictions on Annual Limits on Health Benefits

GAO-11-725R Published: Jun 14, 2011. Publicly Released: Jun 14, 2011.
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The Patient Protection and Affordable Care Act (PPACA), which became law in March, 2010, generally prohibits health insurance issuers and group health plan sponsors from imposing annual limits on the dollar value of "essential" covered health benefits beginning on January 1, 2014, but allows restricted annual limits, as defined by the Secretary of Health and Human Services (HHS), on the value of those benefits until that time. In setting these annual limits, HHS is statutorily required to ensure that individuals' access to needed services remains available with a minimal impact on plan premiums. In June 2010, HHS set restrictions on annual limits for each plan year from September 2010 through December 2013. To mitigate a potential impact on individuals' access or premiums for existing plans with benefit limits below these amounts, HHS established a waiver program based on the statutory requirement. Under the program, issuers or other group health plan sponsors could apply for a waiver from the annual limits set by HHS if they attested and presented evidence that meeting the annual limits would result in diminished access to benefits or a significant increase in premiums. To implement various provisions of PPACA, including those related to annual limits, HHS created what is now called the Center for Consumer Information and Insurance Oversight (CCIIO). CCIIO is now a part of the Centers for Medicare & Medicaid Services (CMS). The Department of Defense and Full-Year Continuing Appropriations Act for Fiscal Year 2011 directed GAO to report on annual limit waiver requests. Specifically, we examined (1) the number of applications that CCIIO received for an annual limit waiver and how many of these were approved or denied and (2) the reasons provided by CCIIO for approvals and denials of annual limit waivers.

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