Feds Prepare New Rules to Bolster Health Care Exchanges

Changes come as marketplaces face uncertain future under President Trump

The Department of Health and Human Services has finalized a slew of new regulations to improve how the Patient Protection and Affordable Care Act (PPACA) marketplaces function, even though their future remains uncertain as Donald Trump prepares to enter the White House, according to a report from FierceHealthcare.

The 2018 Notice of Benefit and Payment Parameters final rule includes payment parameters and provisions related to the risk adjustment program; cost-sharing parameters and cost-sharing reductions; and user fees for federally facilitated exchanges and state-based exchanges on the federal platform. It also provides additional guidance related to standardized options; qualified health plans; consumer assistance tools; network adequacy; the Small Business Health Options programs; stand-alone dental plans; fair health insurance premiums; guaranteed availability and guaranteed renewability; the medical loss ratio program; eligibility and enrollment; appeals; consumer-operated and -oriented plans; special enrollment periods; and other related topics.

The new regulations will go into effect on January 17, 2017––three days before Trump takes the oath of office.

With its latest rules, the Obama administration seeks to “leave the marketplaces on a stable path that, when fully implemented, will ensure quality coverage is available for all Americans well into the future,” Centers for Medicare and Medicaid Services (CMS) acting administrator Andy Slavitt said in an announcement.

A CMS fact sheet outlined some key provisions in the final rule:

  • It updates standardized plan options for all six metal levels on the exchanges—also known as Simple Choice plans—based on an analysis of individual market data from 2016. The final rule also creates three sets of standardized options, selecting one at each level of coverage for each state, based on that state’s cost-sharing requirements.
  • Starting in 2018, the four states involved in a CMS pilot effort to display information about the breadth of plans on Healthcare.gov will also identify whether a particular plan is offered as part of an integrated provider delivery system.
  • The final rule adds new consumer protections related to direct enrollment for marketplace plans, specifying that insurer or broker websites must display standardized options and information about advance premium tax credits. They also must demonstrate “operational readiness” before their sites can be approved to complete plan selection.
  • The rule allows insurers to extend the deadlines for binder payments—or the first premiums paid on a plan—if they are experiencing billing or enrollment problems because of high volume or technical errors.
  • The rule codifies several special enrollment periods (SEPs) “to ensure the rules are clear and to limit misuse.” Insurers have argued that SEPs are vulnerable to abuse by consumers, but the final rule notes that an examination of enrollment data suggests that any such gaming of the system, “if it is occurring, does not appear to be occurring at sufficient scale to produce statistically measurable effects.”

Sources: FierceHealthcare; December 19, 2016; DHS Final Rule; December 2016; and CMS Announcement; December 16, 2016.