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How Does The Federal Health Law Affect Insurance Price Hikes?

Buying health insurance, even on the exchanges created by the health law, can be an expensive proposition. And some consumers are already wondering how much coverage will cost next year. That led to a recent question about the rules that apply to insurance premiums.

I understood that under the health law, premiums for individuals could not increase by double digits, that rate increases were capped at under 10 percent unless approved by the government. Isn't that right?

The health law requires insurers in the individual and small group markets that propose premium increases of 10 percent or more to disclose publicly that information and explain why they think the increase is justified. You can find details of proposed increases on many state websites, and a consumer-friendly version of the information will soon be available on, according to an official at the Centers for Medicare & Medicaid Services.

States, which have primary responsibility for regulating insurance rates, provide varying degrees of oversight. Some don't permit insurers to raise rates without state insurance department approval, while others require insurers to inform states of proposed changes, and states may retroactively reject them.

Some states have no authority over premium rate hikes at all. Under the health law, the federal government reviews rate increases if states don't have an effective process in place.

However, unless states that have the authority to do so step in, "once an insurer files a justification [for an increase over 10 percent], nothing in the Affordable Care Act prohibits them from proceeding," says Timothy Jost, a law professor at Washington and Lee University who is an expert on the health law.

The health insurance marketplaces also have the authority to take insurers' proposed rates into consideration when deciding whether to accept a plan on the exchange, says Jost.

Other provisions of the health law act as a brake on unreasonable rate increases. For example, insurers are required to spend at least 80 percent of the premiums they collect on medical claims or quality of care improvements. If they don't meet that standard, called a medical loss ratio, insurers have to return the extra premium amounts to consumers.

I am concerned that few family doctors in my area are accepting new Medicare patients. Is there a requirement that doctors who work for hospitals accept them? For example, if hospital X buys physician practice Y and pays those physicians a salary, are they required to accept Medicare patients?

No, physicians aren't generally required to accept new Medicare patients, whether or not the doctors are employed by a hospital.

There are many reasons a doctor might refuse a new patient. Her practice may already be full, for example, or she may decide she lacks the necessary expertise to treat someone's condition.

But the vast majority of physicians do in fact accept new Medicare patients, according to a recent study by the Kaiser Family Foundation (Kaiser Health News is an editorially independent program of the foundation.)

In its analysis of the 2012 National Ambulatory Medical Care Survey-National Electronic Health Records Survey, the foundation found that 91 percent of physicians reported that they were accepting new Medicare patients, the same rate as those accepting privately insured patients. Among primary care physicians, the figure was slightly lower, 88 percent.

The study also found that the number of physicians who bill Medicare continues to grow at the same rate as the growth in beneficiaries, staying constant at 3.8 primary care physicians per 1,000 beneficiaries.

Copyright 2023 Kaiser Health News. To see more, visit Kaiser Health News.

Michelle Andrews
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