By John H. Fisher II
February 17, 2017
On February 17, 2017, the Centers for Medicare & Medicaid Services (CMS) published a proposed rule aimed at reforming and stabilizing the individual and small group health insurance markets. When (or if) finalized, the proposed rule would make changes to special enrollment periods, the annual open enrollment period, guaranteed availability, network adequacy rules, essential community providers, and actuarial value requirements. CMS states its belief that the proposed regulations would provide more flexibility to states and insurers, give patients access to more coverage options, and stabilize individual and small group health insurance markets while future reforms are being debated.
The primary changes proposed in the regulations include:
- Expansion of pre-enrollment verification of eligibility to individuals who newly enroll through special enrollment periods in Marketplaces using the HealthCare.gov platform. CMS intends this proposed change to help make sure that special enrollment periods are available to all who are eligible while requiring individuals to submit supporting documentation, a common practice in the employer health insurance market. The intent is to help place downward pressure on premiums, curb abuses, and encourage year-round enrollment.
- Addressing potential abuses by 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 will incentivize patients to avoid coverage lapses.
- Adjustments to the de minimis range used for determining the level of coverage by providing greater flexibility to issuers to provide patients with more coverage options.
- Reaffirming the traditional role of states to serve their populations by moving network adequacy reviews to the states. When reviewing QHPs, CMS would defer network adequacy reviews in states with the authority and means to assess issuer network adequacy.
- Statement of CMS’ intention to release a revised proposed timeline for the QHP certification and rate review process for plan year 2018. The revised timeline would provide issuers with additional time to implement proposed changes that are finalized prior to the 2018 coverage year. These changes will give issuers flexibility to incorporate benefit changes and maximize the number of coverage options available to patients.
- Shortening of the upcoming annual open enrollment period for the individual market. For the 2018 coverage year, CMS proposes an open enrollment period of November 1, 2017, to December 15, 2017. The stated intent is to align the Marketplaces with the Employer-Sponsored Insurance Market and Medicare. This may help lower prices for Americans by reducing adverse selection.
Obviously, all of the regulations pertaining to the Affordable Care Act are up in the air pending potential Congressional action on the underlying statutes. Given the current uncertainty, CMS appears to be moving forward with revisions to the health care program that it intends to add stability to costs and operation. The last day for public comments to be received on the proposed regulations is March 7, 2017.
My analysis of these regulations…this could get interesting.
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