Health Reform WK-EDGE Idaho notified of failure to enforce ACA marketplace requirements
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Monday, March 19, 2018

Idaho notified of failure to enforce ACA marketplace requirements

By Susan Smith, J.D., M.A.

CMS has notified Idaho’s Governor and Director of the state’s Department of Insurance that based on its review of Idaho Bulletin No. 18-01, Provisions for Health Carriers Submitting State-Based Health Benefit Plans, the state may not be substantially enforcing provisions of the Patient Protection and Affordable Care Act (ACA) (P.L. 110-148) related to the health insurance marketplace (see ACA secs. 1001, 1201, 1563, 10101, 10103, and 10107). The state has 30 days from the date of CMS’ notice to respond unless the time for the response is extended. If at the end of the 30-day period CMS determines that the state has failed to substantially enforce the applicable Public Health Service Act (PHS Act) Title XXVII Part A requirements, it will provide the state an opportunity to show evidence of substantial enforcement. If the state fails to show it has corrected any failure to substantially enforce the requirements, CMS has the responsibility to enforce Part A market requirements (CMS Letter, March 8, 2018).

Areas of noncompliance. The CMS Letter describes the requirements of Idaho’s new health products called "State-based plans," found in Idaho Bulletin No. 18-01 that appear to be noncompliant and provides the language of the PHS requirements. Specific requirements for the plan that seem to be noncompliant include:

  • pre-existing condition coverage, Sec. 2704;
  • premium rates, Sec. 2701;
  • annual limits, Secs. 2703 and 2711;
  • medical underwriting/risk factor, Secs. 2701 and 2705;
  • essential health benefits, prescription drugs, and maximum out of pocket, Sec. 2707; and
  • preventive services, Sec. 2713.

CMS believes that with certain modifications Idaho’s state-based plans could be legally offered under the PHS Act exception for short-term, limited duration plans. If the state is willing and able to assume the enforcement authority of the Part A market requirements, CMS will work with the state to ensure an effective transition.

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