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Industry Spotlight > Broker Dealers

CMS hates some agents and other draft 2017 PPACA parameters

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The Centers for Medicare & Medicaid Services focuses more on creating a line of easy-to-compare health insurance products in a major new batch of draft insurance rules, and punishing rogue agents and brokers, then on offering insurers new reasons to put plans on exchange shelves. 

The document

CMS, an arm of the U.S. Department of Health and Human Services (HHS), has included the standard options plan proposal, new producer disciplinary provisions, and many tweaks to PPACA exchange system rules and commercial health insurance rules in a 381-page PDF file, “Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2017.”

See also: PPACA World 2016: Dates, risks, flops and 5 things those big HHS PPACA ‘parameter’ regs say about agents

CMS is preparing to publish the draft regulations in the Federal Register Dec. 2. Comments will be due Dec. 21.

The contacts listed include Melissa Jaffe, for risk corridors matters, Lisa Cuozzo, for the rate review process; Jennifer Stolbach, for state-based exchange matters; and Briana Levine, for matters related to agents and brokers.

What’s in there for insurers?

Executives at UnitedHealth Group Inc. (NYSE:UNH) pointed out Thursday that they are seeing people with health problems acting as “free riders,” and enrolling in exchange coverage, through the special enrollment period (SEP) process, only when they are sick. On page 163 of the PDF, CMS suggests that it might rewrite the SEP rules to let an exchange cancel fraudulent enrollments retroactively.

CMS has also proposed making complicated changes to the PPACA “three R’s” risk management program reporting procedures that might have mixed effects on insurers.

Some insurers and others have complained about the PPACA individual major medical open enrollment period overlapping with the Medicare plan open enrollment period. 

CMS officials have proposed having the open enrollment period for 2017 coverage run from Nov. 1, 2016, through Jan. 31, 2017, and continue to overlap with the Medicare open enrollment, because, they say, that may help some consumers switch between major medical coverage and Medicare coverage. (Page 162)

CMS has suggested that the 2017 out-of-pocket maximum might be $7,150 for an individual and $14,300 for a family. (Page 171)

See also: States gear up for the PPACA reboot year

CMS is not trying to ban balance billing, but it says patients who get out-of-network care in in-network settings, such as hospitals, should be able to count what they spend on out-of-network essential health benefits care toward their annual out-of-pocket spending maximums. (Page 230)

Standardized options plans

Some consumer groups have complained that consumers using have a hard time making true apples-to-apples comparisons because of big differences in plan cost-sharing rules. 

CMS has proposed nudging plan issuers toward more uniformity by using to highlight plans offered by issuers that voluntarily agree to base plans on a standardized benefits template. (Page 198)

The standardized option silver plan, for example, would have a $3,500 deductible, a $7,150 out-of-pocket maximum. After a patient met the deductible, the co-pay for emergency room services would be $300. An urgent care visit would not be subject to the deductible, and the co-payment would be $75. (Page 204)

Broker provisions

In provisions that apply to the exchanges that use the HHS enrollment system, CMS has proposed eliminating the requirement that the vendors responsible for training exchange agents verify those agents’ identity. (Pages 144 to 146) The exchange plan issuers already have to verify agents’ identity, so, there is no reason for the training vendors to also have to verify the agents’ identity, CMS says.

CMS would also let Web brokers handle the application process on their own systems, and connect with only for eligibility verification purposes, rather than forcing Web brokers to channel customers to for the application process.

But CMS has also included a long section on agent and broker disciplinary rules. (Pages 136 to 144) Officials have focused heavily on concerns about cases of producer fraud and abuse related to use of consumers’ personally identifiable information.

See also: NAIC fraud alert highlights consumers’ PPACA ignorance

Under a proposed regulation, “if HHS reasonably confirms the credibility of an allegation that an agent or broker engaged in fraud or abusive conduct using personally identifiable information of exchange enrollees or applicants, or in connection with an exchange enrollment or application, or is notified by a state or law enforcement authority of the state or law enforcement authority’s finding or determination of fraud or behavior that would constitute abusive conduct in such a circumstance, HHS will notify the agent or broker and terminate, immediately and permanently, the agent’s or broker’s agreements with the [exchange system] for cause,” CMS says.

“While states remain the primary oversight authority for agents and brokers, HHS reserves the right to take any other permissible enforcement or remedial action against an agent or broker for violation of federal requirements,” CMS says.

An agent or broker could appeal a termination action, CMS says.

CMS has not proposed a similar set of provisions for navigators or other types of non-agent, non-broker exchange helpers.


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