Health Reform WK-EDGE Guidance creates new flexibilities in state innovation
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Thursday, October 25, 2018

Guidance creates new flexibilities in state innovation

By Patricia K. Ruiz, J.D.

CMS, in collaboration with the Department of the Treasury, (the Departments, collectively) released new guidance to increase choice and competition within the insurance market, while also protecting people with pre-existing conditions. The guidance allows states to pursue new State Relief and Empowerment Waivers to improve their individual insurance markets, increase affordable coverage options for residents, and ensure that those with pre-existing conditions are protected. This guidance replaces prior guidance related to section 1332 of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) (Notice, 83 FR 83575, October 24, 2018).

Supporting state innovation. Through this guidance, the Departments enable states to seek innovative ways to improve insurance markets and develop more effective approaches to increase choice and affordability for enrollees. When considering applying for a waiver, states can consult this guidance, which outlines five principles for states to follow when developing innovative new approaches: (1) provide increased access to affordable private market coverage; (2) encourage sustainable spending growth; (3) foster state innovation; (4) support and empower those in need; and (5) promote consumer-driven health care.

Loosening ACA waiver requirements. This guidance replaces previous guidance on section 1332 published in 2015 (see Seeking state innovation waiver? No surprise, stick to ACA goals, December 16, 2015). The new guidance loosens controls set by the initial guidance, creating additional flexibilities for states, including:

  • allowing states to provide consumers with plan options that best meet their needs while ensuring those with pre-existing conditions retain access to the same level of coverage available today;
  • continuing to require that a comparable number of people have coverage, while expanding the definition of coverage to include more types (such as short-term plans);
  • providing greater flexibility for states to consider improvements for state residents as a whole, rather than for specific populations;
  • supporting increased variation and flexibility for states that want to leverage components of the federal exchange to implement new models; and
  • providing flexibility for states to meet the state legislative authority requirement.

The guidance also loosens the Departments’ evaluation of statutory guardrails related to comprehensiveness and affordability of coverage, the number of state residents covered, and deficit neutrality.

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