Insurers and hospitals can’t discriminate against patients because of their gender identity under the Affordable Care Act, federal officials said Friday, but patient groups complained the rule doesn’t go far enough.

The Department of Health and Human Servicesfinalized a rule that prohibited discrimination in health care based on a long list of characteristics ranging from race to pregnancy, gender identity and “sex stereotyping.”

It doesn’t mean insurers have to cover all treatments associated with gender transitioning but they just can’t outright deny them either. But the rule doesn’t go far enough in clarifying what is discrimination, some say.

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The CMS unveiled an interim final rule late Friday that could help the Affordable Care Act’s struggling co-op plans. The rule also responds to insurers’ complaints that people are abusing special enrollments in the exchanges.

The CMS tightened the use of special enrollments, specifically making the rules around moving to a new home more restrictive to avoid any gaming of the system. Co-ops also can seek outside funding from investors to build up their capital, something that was outlawed previously.

Nearly 25% of Americans surveyed last September who had coverage through employer plans, the Affordable Care Act exchanges, or individual plans outside the exchanges reported problems paying family medical bills in the previous 12 months, according to the Urban Institute’s Health Reform Monitoring Survey, released last month. That compared with 16% of people on Medicaid and 27.8% of uninsured individuals who said they had problems with medical bills.

The Kaiser Family Foundation reached similar findings through focus group interviews with 91 low-income Medicaid and exchange-plan enrollees in six cities during January and February 2016.

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Insurers are in the process of filing proposed premiums for ACA-compliant nongroup plans that will be available inside and outside of Marketplaces in 2017.

Recent reports by insurers about their experiences during the first two years under the ACA suggest that some assumed that enrollees would be healthier than they turned out to be and set their premiums too low, leading in some cases to significant financial losses for ACA-compliant plans and an expectation that premiums could rise faster in 2017. Some insurers took relatively large premium increases for 2016 to better match premium levels with the costs of their enrollees — which would help to offset the need for 2017 premium increases — but it is too soon to know if these efforts were generally successful or whether losses have continued into 2016.

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It already looks clear that many Obamacare insurance plans are going to raise their prices significantly.

Over the last few years, average premium increases in the ObamaCare markets have been lower than the increases for people who bought their own insurance in premiums before the Affordable Care Act. But several trends are coming together that suggest that pattern will break when plan premiums are announced in early November. Many plans may increase prices by 10 percent, or more.

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Insurers have begun to propose big premium increases for coverage next year under the 2010 health law, as some struggle to make money in a market where their costs have soared.

The companies also have detailed the challenges in their Affordable Care Act business in a round of earnings releases, the most recent of which came on Wednesday when Humana Inc. said it made a slim profit on individual plans in the first quarter, not including some administrative costs, but still expects a loss for the full year. The Louisville, Ky.-based insurer created a special reserve fund at the end of last year to account for some expected losses on its individual plans in 2016.

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In the face of losses in the Affordable Care Act marketplace, Blue Cross and Blue Shield of Illinois is looking for new ways to cut spending.

Starting June 1, the Chicago-based health insurer will no longer accept credit cards as a form of payment for members who buy their own health insurance on or off the Illinois marketplace. The company began notifying customers of the change last month. Blue Cross will still accept other forms of payment, including debit cards.

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UnitedHealthcare’s decision to not offer Affordable Care Act exchange plans next year in “at least 26 of the 34 states where it sold 2016 coverage” may soon be followed by similar announcements from other health care insurers.

At least that is one implication that can be drawn from the findings reported in a new paper analyzing the performance of insurers that offered exchange coverage in 2014.

The paper’s authors—Heritage Foundation senior research fellow Ed Haislmaier, Mercatus Center senior research fellow Brian Blase, and Galen Institute senior fellow Doug Badger—examined enrollment and financial data for the 289 Qualified Health Plans sold on the exchanges in 2014.

They found that, in the aggregate, insurers incurred substantial losses offering exchange coverage. Furthermore, the poor results were despite insurers receiving substantial subsidies—indeed, more than they originally expected—through the Affordable Care Act’s “reinsurance” program.

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When UnitedHealth, the nation’s largest health insurer, announced earlier this month that it would exit the Affordable Care Act exchange business in all but three states, the obvious question was, who’s next? After all, if the nation’s biggest health carrier can’t make the Obamacare exchanges profitable, who can? UnitedHealth announced it expects to lose $650 million on its ACA business in 2016, although its first-quarter earnings beat analyst expectations, thanks to the company’s highly profitable consulting and technology businesses.

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Expect insurers to seek significant premium increases under President Barack Obama’s health care law, in a wave of state-level requests rippling across the country ahead of the political conventions this summer.

Insurers say the law’s coverage has been a financial drain for many of them, and they’re setting the stage for 2017 hikes that in some cases could reach well into the double digits.

For example in Virginia, a state that reports early, nine insurers returning to the HealthCare.gov marketplace are seeking average premium increases that range from 9.4 percent to 37.1 percent.

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