Before President Trump and Congressional Republicans fulfill their promises to repeal and replace the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148), they need to stabilize the ACA until a new plan is enacted and takes effect. To that end, the Trump Administration issued a Proposed rule designed to stabilize the individual and small group markets by addressing some of insurers' concerns in hopes of keeping them in the marketplace. The Proposed rule would change the standards relating to special enrollment periods (SEPs), guaranteed availability, the timing of the annual open enrollment period (OEP) in the individual market for the 2018 plan year, network adequacy and essential community providers for qualified health plans (QHPs), and the rules around actuarial value requirements. It also announces upcoming changes to the qualified health plan certification timeline (Proposed rule, 82 FR 10980, February 15, 2017).
Need for stabilization. CMS asserts in the rule that the viability and competitiveness of the marketplaces have been threatened by insurer exit and increasing rates in many geographic areas.
Guaranteed availability of coverage. Section 1201 of the ACA requires health insurance issuers offering non-grandfathered coverage in the individual or group market to offer coverage to and accept every individual and employer in the state that applies for such coverage unless an exception applies. However, due to concerns of gaming the system by non-payment of premiums, the rule proposes allowing an issuer to collect premiums for prior unpaid coverage, before enrolling a patient in the next year’s plan with the same issuer. This is designed to incentivize patients to avoid coverage lapses.
Initial and annual open enrollment periods. Section 1311(c)(6)(B) of the ACA gives the HHS Secretary the authority to set the dates for annual enrollment periods. The rule proposes to change the change the OEP for plan year 2018 so that it begins on November 1, 2017, and ends on December 15, 2017. Under the rule, all consumers who select plans on or before December 15, 2017 would continue to receive an enrollment effective date of January 1, 2018. CMS believes that this OEP would align better with many OEPs for employer-based coverage, as well as the OEP for Medicare.
Special enrollment periods. Section 1311(c)(6)(C) of the ACA requires the Secretary to provide SEPs to ensure that people who lose coverage during the year, or who experience other qualifying events such as marriage or the birth of a child, have the opportunity to enroll in new coverage or make changes to existing coverage. In many cases, CMS has permitted individuals to self-attest to their change in circumstances and to enroll during SEPs without further verification.
The rule proposes to expand pre-enrollment verification of eligibility to individuals who newly enroll through SEPs. This proposed change would help make sure that SEPs are available to all who are eligible for them, but will require individuals to submit supporting documentation, a common practice in the employer health insurance market. It is hoped that this requirement will help place downward pressure on premiums, curb abuses, and encourage year-round enrollment.
Level of coverage (actuarial value). Section 1302 of the ACA directs issuers of non-grandfathered individual and small group health insurance plans, including QHPs, to ensure that these plans adhere to the levels of coverage specified in section 1302(d)(1) of the ACA. A plan’s coverage level, or actuarial value (AV), is determined based on its coverage of the essential health benefits for a standard population. Section 1302(d)(1) of the ACA requires a bronze plan to have an AV of 60 percent, a silver plan to have an AV of 70 percent, a gold plan to have an AV of 80 percent, and a platinum plan to have an AV of 90 percent. Section 1302(d)(3) of the ACA authorizes the Secretary to develop guidelines to provide for a de minimis variation in the actuarial valuations used in determining the level of coverage of a plan to account for differences in actuarial estimates.
CMS believes that further flexibility is needed for the AV de minimis range for metal levels to help issuers design new plans for future plan years, thereby promoting competition in the market. Therefore, CMS proposes amending the definition of de minimis to a variation of -4/+2 percentage points, rather than +/-2 percentage points for all non-grandfathered individual and small group market plans that are required to comply with AV. CMS believes that a de minimis amount of -4/+2 percentage points would provide the necessary flexibility to issuers in designing plans while striking the right balance between ensuring comparability of plans within each metal level and allowing plans the flexibility to use convenient and competitive cost-sharing metrics.
Network adequacy. Section 1311(c)(1)(B) of the ACA gives the Secretary the authority to establish minimum criteria for network adequacy that health and dental plans must meet to be certified as QHPs. In recognition of the traditional role states have had in developing and enforcing network adequacy standards, the rule proposes, in the review of QHPs, to defer to the states’ reviews in states with the authority and means to assess issuer network adequacy.
Certification calendar update. In light of the need for issuers to make modifications to their products and applications to accommodate the changes proposed in the proposed rule, CMS plans to issue separate guidance to update the QHP certification calendar and the rate review submission deadlines to give additional time for issuers to develop, and states to review, form and rate filings for the 2018 plan year that reflect these changes.
Comments on the Proposed rule must be submitted by March 7, 2017.
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