Officials at the Trump administration’s Centers for Medicare & Medicaid Services want to give health insurers more time to file Affordable Care Act exchange plan product forms and rates for the 2018 open enrollment period.
CMS officials do not say how much time they expect to give insurers. But if the draft regulations are adopted, officials say they will give issuers and states extra time to help them adjust to the rule changes.
CMS officials also want to shorten the 2018 open enrollment period, get much tougher on consumers who abuse the ACA special enrollment period system, trim how much actuarial value a plan has to provide, and ease provider network requirements.
CMS, an arm of the U.S. Department of Health and Human Services, has included those provisions in draft ACA exchange stabilization regulations that are on track to appear in the Federal Register Friday.
Officials at the federal Office of Management and Budget completed reviews of the draft Feb. 10.
The draft lists career CMS employees and officials who came in during the Obama administration as the contact people. But the OMB tracking system also shows that Marie Meszaros, a Trump administration health policy transition specialist, attended an OMB meeting on the draft with representatives from the Blue Cross and Blue Shield Association.
Public comments on the draft regulations will be due March 7.
Republicans in Congress and President Donald Trump have talked about wanting to repeal or repair the Affordable Care Act. Some Republicans in Congress have suggested that they might not be able to propose an alternative to the current version of the ACA until sometime this summer, and some Republicans have introduced ACA replacement outlines that could let some form of the ACA exchange system continue to exist.
The drafters of the new proposed regulations assume in the text that the current version of the ACA and Obama administration ACA regulations will remain in effect for the rest of the year and in 2018.
One of the main defenses insurers still have against health risk is the calendar. (Image: Thinkstock)
In the new draft exchange regulations, CMS officials focus mainly on efforts to shore up the current individual market open enrollment period and special enrollment period programs.
CMS is looking hard at the calendar, because the calendar is one of the only weapons the Affordable Care Act lets insurers use to try to make the people they enroll as healthy as possible
The ACA eliminated many of the defenses health insurers once used to limit health risk.
The ACA now blocks issuers from considering personal health factors other than location when deciding whether to issue coverage, and from considering factors other than location, age and tobacco use when setting prices for individual and small-group coverage.
Regulators, issuers and ACA exchange managers developed the open enrollment period system to try to scare consumers away from seeing the new underwriting restrictions as an invitation to wait until they get sick to pay for coverage.
Consumers can get coverage easily during the open enrollment period. At other times of the year, a consumer who wants coverage must apply for a special enrollment period. To qualify for SEPs, consumers must show a health insurer or the ACA exchange system that they have what the government classifies as ‘a good excuse’ to shop for coverage outside the open enrollment period.
Originally, the ACA exchange system let people get SEPs by swearing that they qualified for them. Applicants did not have to prove that they were eligible for the SEPs.
About 18 months ago, insurers began complaining that SEP enrollees had much higher bills than other enrollees. Insurers said they believed the higher average SEP enrollee claim costs were a sign that some SEP enrollees were people who waited until they got sick to pay for coverage.
Managers of some locally based exchanges, such as the exchange that serves the District of Columbia, have said that they see little evidence of SEP abuse.
But managers of other state-based exchanges and of HealthCare.gov, the exchange enrollment system HHS set up for states that did not want to run their own exchange systems, started creating tougher documentation requirements and eligibility screening programs for SEP applicants.
Managers of HealthCare.gov, for example, said they would require documentation from half of SEP applicants and no documentation from the other half. They hoped to then compare the results for the full-screening and no-screening applicants.
In the new draft regulations, CMS officials say they are thinking of the following ideas:
1. Changing the open enrollment period end date.
The open enrollment period for 2018 is now set to start Nov. 1 and end Jan. 31, 2018.
If all individual coverage issuers end the open enrollment period Dec. 15, that will give consumers an extra incentive to sign up for coverage during the open enrollment period, and to avoid the possibility of getting sick and having no good way to pay for care at other times of the year, officials say.
The current open enrollment period calendar applies to all individual coverage issuers, in both the exchange and off-exchange markets, and in both HealthCare.gov states and states with locally run exchange programs.
Apparently, the proposed open enrollment period end date change could, possibly, apply only to HealthCare.gov plan issuers.
The officials ask for comments on how well state-based exchanges, agents and brokers could adapt to a shorter enrollment period.
2. Setting tougher SEP rules.
Officials say they want to require all HealthCare.gov SEP applicants to document their eligibility for SEPs starting in June 2017.
HealthCare.gov would let the SEP applicants rely as much as possible on electronic documentation, rather than requiring the applicants to mail in or upload copies of paper documents.
Officials are asking whether they should make state-based exchanges require documentation from all SEP applicants, and whether it would be OK to leave a small group of enrollees out of the verification process, to serve as a study control group.
3. Cracking down on specific types of SEP abuse.
CMS officials say they have heard reports of two uninsured people marrying outside the open enrollment period so they can qualify for a marriage-based SEP.
CMS wants to require that at least one spouse in a newly married couple that’s applying for a marriage-based SEP previously had health coverage, at least briefly, during the 60-day period before the couple applies for the marriage-based SEP. Officials would make exceptions for some types of couples that might not be able to meet that requirement, such as couples who had been located outside the United States before applying for the marriage-based SEP.
CMS also wants to find a way to keep consumers who already have bare-bones health coverage from using SEPs to move up to more expensive, richer coverage when they get sick. Officials say they might simply prohibit exchange plan users from using SEPs to change coverage levels during the course of a year.
CMS officials also want to make some other rules more appealing to insurers.
The metal level system helps consumers understand how rich a health plan’s benefits are. (Image: Thinkstock)
Other proposed changes
Exchange plan issuers are supposed to show they have enough health care providers in their networks to meet enrollee needs.
CMS wants to cut down on the number of providers a plan has to have in its provider network.
For 2018, an issuer could have contracts with just 20 percent of the “essential community providers” in a service area, rather than the 30 percent now required.
Another change could ease the boundaries between plan “metal levels,” or richness categories.
A bronze plan is supposed to cover about 60 percent of the actuarial value of a standard benefits package.
The value percentage is about 70 percent for a silver plan, 80 percent for a gold plan and 90 percent for a platinum plan.
In the real world, CMS has let plans be off by 2 percentage points. A bronze plan, for example, can really cover 58 percent to 62 percent of the value of the standard benefits package.
CMS wants to cut the minimum value level for each metal level by 2 percentage points.
A bronze plan, for example, could cover 56 percent to 62 percent of the value of the standard benefits package in 2018, and a platinum plan could cover 86 percent to 92 percent of the value of that package.
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