By Robert B. Barnett Jr., J.D.
The CMS 2020 Letter, which updates operational and technical guidance for insurers interested in participating in the ACA exchanges in 2020, sets forth the 2019 deadlines for 2020 participation.
CMS has released its "2020 Letter," which is an update on operational and technical guidance for insurers interested in participating in the Patient Protection and Affordable Care Act (ACA) exchanges in 2020. The letter describes few changes from the rules established in prior years, with the most important piece of information being the 2019 deadlines for 2020 participation (CMS Letter, April 18, 2019).
The guidance applies to qualified health plans (QHPs) in the federally facilitated exchanges (FFEs) or the federally facilitated Small Business Health Options Program (FF-SHOPs). The QHP guidance also includes stand-alone dental plans. The application process applies to all states in which an FFE operates, including: (1) states performing plan management functions and making QHP certification recommendations to CMS; (2) states where CMS is performing all plan management functions while the state is enforcing ACA standards; and (3) direct enforcement states where CMS is only enforcing general ACA standards.
QHP certification. The CMS letter walks through the QHP certification process for 2020, which is mostly unchanged for prior years, other than the new application deadline dates. For 2020 QHPs, the initial application submission window is April 25, 2019, to June 19, 2019. CMS will review the QHP applications from June 20, 2019, to August 2, 2019. Issuers will return signed agreements between September 16, 2019, and September 24, 2019. CMS will release certification notice to issuers and states on October 3 and 4, 2019, and open enrollment will begin on November 1, 2019. Those are the general application deadlines. The letter contains numerous other deadlines for various related processes, including data corrections.
Early Bird. The Letter says that, new for 2020, the table of deadline dates includes key dates for those issuers that want to use the Early Bird submission process to submit data before the first formal submission deadline. The advantage of using Early Bird is that issuers resolve corrections early and can avoid a corrections notice during the regular submission process. The Early Bird data submission deadline is May 22, 2019. CMS review of the Early Bird submissions will be conducted from May 23, 2019, through June 11, 2019.
Data changes. Another significant part of the QHP application process is data changes that issuers make to their own applications on their initiative (i.e., not in response to CMS comments). Issuers, of course, may make such changes at any point during the general application process timeline, from April 25, 2019, to June 19, 2019. During the June 20-August 21, 2019, CMS review timeline, once CMS approves a change the issuer has made, the issuer may not change again without CMS or state approval, other than to change its service area. After August 21, 2019, an issuer may change its QHP application only as directed by CMS or the state.
Other processes. The various other processes, such as for quality reporting, discriminatory benefit design, cost sharing issues, and prescription drugs, remain largely unchanged from prior years, with four small exceptions.
Cost-sharing reduction plan variations. It its 2020 Payment Notice final rule for compliance with 45 C.F.R. § 156,420 for cost-sharing reduction plan variations, CMS established different annual limits on cost sharing than those outlined in the 2018 Letter to Issuers.
FFE oversight. In the 2020 Payment Notice final rule, CMS established several changes to FFE oversight mechanisms for QHP issuers participating in direct enrollment. Issuers should review those changes, specifically the changes affecting 45 C.F.R. § 155,220-221 and 155.415. The final rule also made further changes to standards for direct enrollee entities and for third-parties to audit direct enrollment entities.
FF-SHOPs. After the substantial changes made to FF-SHOP operations in the 2019 Payment Notice final rule, CMS made far fewer in the 2020 Payment Notice final rule. One change was to allow FF-SHOPs to operate leaner, by allowing them to operate a toll-free telephone hotline and by eliminating the requirement that they operate a more robust call center.
SBE-FP. Most state-based exchanges on the federal platform will not be affected by 2020 changes because the federal platform agreement runs from January 1, 2018, to January 1, 2023. States newly transitioning to the federal platform, however, will be affected. The 2020 Payment Notice final rule will assess an SBE-FP a federal user rate of 2.5 percent of the monthly premium charged by the issuer for each policy under plans offered through an SBE-FP.
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