Federal law market rules for private health insurance sold to individuals and groups Individual Market Insurance Small Group Market Insurance Large Group Market Insurance Pre-ACA Post-ACA Guaranteed issue NO** YES NO Rating based on health status prohibited Gender rating prohibited Discrimination within groups prohibited NA Pre-ex exclusions prohibited Pre-ex exclusions limited to 12 months with credit for prior coverage Guaranteed renewability required Rescissions prohibited * States could have stronger laws and several did. For example, before the ACA, some states required guaranteed issue individual market coverage (see: https://www.kff.org/state-category/health-insurance-managed-care/). The market rules in this table apply to fully insured plans sold to individuals and groups; self-funded employer plans don’t buy insurance, but rules related to nondiscrimination and pre-existing condition exclusions still apply to those plans. **Before the ACA, insurers were required to guarantee issue certain policies, and were prohibited from imposing pre-ex exclusions only for a select group of HIPAA-eligible individuals, who had 18 months of prior continuous coverage, were leaving group health plans, and met other requirements. Under HIPAA, states had flexibility to use alternative mechanisms (such as high-risk pools) to provide guaranteed issue, no-pre-ex coverage to eligible individuals and nearly all did so.