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3 darts for agents in the new ACA 2018 draft rules

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The Obama administration is starting to set the rules for how HealthCare.gov and other Affordable Care Act programs and rules might work in 2018.

The Centers for Medicare & Medicaid Services, an arm of the U.S. Department of Health and Human Services, already is gearing up to open the fourth ACA individual major medical coverage open enrollment period, which is set to start Nov. 1 and run until Jan. 31, 2017.

Related: CMS posts 2017 PPACA World rules

Even if Donald Trump wins the presidential election Nov. 8 and enters the White House with strong majorities in both the House and the Senate in January, he might have trouble making big changes in ACA programs until 2018.

A President Trump, or a President Hillary Clinton, probably could play a big role in shaping how ACA programs work, or disappear, in 2018.

But CMS is preparing for the possibility that the ACA system will work roughly the same way in 2018 that it works now. The agency is on track to publish a draft of a key ACA system framework document, Benefit and Payment Parameters for 2018, in the Federal Register Sept. 6. 

An early version of the framework draft is already available here.

Comments will be due 30 days after the publication date.

CMS runs HealthCare.gov, an ACA enrollment and administration system that provides ACA exchange services that are unwilling or unable to provide the services themselves. CMS also oversees the ACA exchange programs operated by states, and it enforces ACA underwriting and coverage standards rules that apply to the commercial health coverage market.

Many of the provisions apply mainly to the managers of the ACA public exchanges and to major medical coverage issuers.

CMS has proposed, for example, that the fee HealthCare.gov charges plan issuers should stay at 3.5 percent in 2018. The issuer user fee has been set at 3.5 percent since the exchange system opened for business in 2014.

CMS has also sketched out changes in the ACA risk-adjustment program, a program that’s supposed to use cash from issuers that end up with low-risk enrollees to help issuers with high-risk scores. CMS uses information from the issuers to give each enrollee a risk score. Part of the parameters document fleshes out a previously announced system for auditing the enrollee health information that issuers send to the risk-adjustment program administrators.

CMS says it expects total risk-adjustment program user fee revenue to total $35 million in 2018, the same as in 2017. But growth in the number of health plan enrollees covered by the program could reduce the per-user cost of the program to $1.32 per enrollee per year in 2018, from $1.56 per enrollee per year in 2017.

Some proposed provisions could have a direct effect on retail agents, the Web brokers that connect directly with HealthCare.gov systems, or on both retail agents and Web brokers.

Related: Health insurers choose their pipes

Some producers may ask whether any agents or brokers will bother to try to do business with HealthCare.gov in the future, given all of the problems insurers and producers have reported having with the program this year. But a CMS agent registration database shows that, as of Tuesday, the agency had already registered 17,423 agents for the individual market, and 4,277 agents for the Small Business Health Options Program market.

For a look at some of the provisions that could affect agents and Web brokers, read on:

HealthCare.gov (Image: CMS)

An agent’s exchange plan sales site should be different from this, except when it should be the same. (Image: CMS)

1. Producers’ exchange plan sites should be like HealthCare.gov, and not like HealthCare.gov.

HealthCare.gov managers want to stop agents or brokers that enroll people directly in exchange coverage themselves from using marketing names, Web addresses or design practices that could make consumers think they are using HealthCare.gov.

“Our experience shows that Web sites that utilize combinations of colors, text sizes and fonts or layout similar to those used on HealthCare.gov have caused confusion among consumers,” officials say in a preamble to the proposed 2018 regulations.

But, officials say elsewhere in the parameters document, they want any direct-enrollment websites to display consumers’ projected advance premium tax credit subsidy support prominently, just as HealthCare.gov does, and highlight the new, plain-vanilla benefit “Standard Option” plans, just as HealthCare.gov does.

CMS also wants direct-enrollment sites to offer taglines offering more help in the “top 15 languages spoken by the limited English proficient population of the relevant State or States.”

Related: 5 things HealthCare.gov is telling agents and brokers now

Web brokers may have to pay for their data security audits. (Photo: Thinkstock)

Web brokers may have to pay for their data security audits. (Photo: Thinkstock)

2. HealthCare.gov managers are setting up a system for auditing Web brokers, and, possibly, requiring the Web brokers to pay independent firms to do the audits.

HealthCare.gov managers want to be able to cut off connections with agents’ or Web brokers’ sites immediately if the connections appear to pose a data a security risk, and it wants to have someone conduct audits of Web brokers’ “ability to securely collect, maintain and transmit eligibility application information.”

The auditors might be “approved third parties,” and the agents or brokers that engaged the third parties would probably have to pay the third parties, officials say.

Related: You may be a HealthCare.gov “A/B”

CMS is holding the HealthCare.gov plan issuer fee steady at 3.5 percent of the monthly premium. (Photo: Thinkstock)

CMS is holding the HealthCare.gov plan issuer fee steady at 3.5 percent of the monthly premium. (Photo: Thinkstock)

3. The share of premium revenue available for supporting marketing programs will stay flat, and supporters of higher marketing spending will have to fight for their share of the budget pie.

ACA exchange program marketing and outreach campaigns may help sellers of all kinds of insurance products, including health insurance products other than major medical coverage and non-health products, by educating consumers about the value of insurance.

In some cases, ACA exchange marketing activities might expand the potential market for all kinds of financial services products, by helping consumers clear up problems with identification documents and credit reports.

CMS officials note in the preamble to the parameters document that HealthCare.gov has to use its 3.5 percent-of-premium user fee to handle tasks such as eligibility determinations, plan issuer certification processes, HealthCare.gov system updates and “regulation of agents and brokers,” as well as “consumer outreach and education.”

CMS officials note that, in the past, some commenters have said it should spend more on outreach and education.

“We seek comment on how much funding to devote to outreach and education, the method to determine such funding, and the effectiveness of certain outreach investments,” officials say.

Related:

CMS hates some agents and other draft 2017 PPACA parameters

PPACA World 2016: Dates, risks, flops

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