The Trump administration has come out with a 365-page notice that shows how the U.S. major medical insurance market could look in 2019 — if that market still exists, if the current laws stay about the same, and if the administration tries to keep public health insurance exchange program going.
The Centers for Medicare & Medicaid Services (CMS) maps out the future in a draft set of Affordable Care Act (ACA) benefit and payment parameters for 2019, which is scheduled to appear in the Federal Register on Thursday.
(Related: ACA Definitions: Enrollment Period Basics)
In the draft notice, CMS officials suggest that agents and brokers might:
Offer plans that are a little leaner than the plans available today.
Have an easier time finding policies compatible with health savings accounts, and policies based on value-based insurance design principles.
Face fewer, but tougher, navigators.
Have a little bit easier time collecting commissions.
President Donald Trump and Republicans in Congress are trying to replace the ACA. But CMS officials based the parameters draft on the statutes now in effect. They assume, as a given, that the ACA public exchange programs will exist, that the federal government will continue to pay income-based premium tax credit subsidies, and even that the federal government will continue to make cost-sharing reduction subsidy payments to insurers.
CMS officials say in the introduction to the draft that they hope to shore up the health insurance market by enhancing the role of states, empowering consumers, reducing unnecessary regulatory burden on stakeholders, and improving affordability.
Congress developed the ACA in an effort to help sick people get health coverage as easily as healthy people, to provide new health insurance subsidies, and to create exchanges, or web-based health insurance supermarkets. The ACA drafters wanted the exchanges to give individuals and small employers a quick, easy way to shop for health coverage, and to compare plans on an apples-to-apples basis.
The exchange system opened for business Oct. 1, 2013. The first coverage sold took effect Jan. 1, 2014. The next open enrollment period, for 2018 coverage, is set to start Nov. 1, amidst confusion about how many issuers will offer plans and what the market rules will be.
“Over time, issuer exits and increasing insurance rates have threatened the stability of the individual and small group exchanges in many geographic areas,” CMS officials write in the introduction to the parameters draft.
CMS is an arm of the U.S. Department of Health and Human Services (HHS). President Donald Trump issued an executive order in January that calls for the HHS secretary, and other federal department and agency heads, to reduce ACA-related burdens, CMS officials write.
“In this proposed rule, we are proposing, within the limitations of the current statute, to reduce fiscal and regulatory burdens across different program areas, and to support innovative health insurance models,” officials say.
CMS oversees the ACA exchange programs in all 50 states and the District of Columbia. CMS also runs HealthCare.gov, a system that provides exchange enrollment and account administration services for residents of 39 states. Some of the proposed parameters in the new draft would apply in all jurisdictions. Others would apply only in the HealthCare.gov states.
Here’s a look at seven highlights from the draft that might be of interest to insurance agents and brokers.
1. What’s missing
One of the most important highlights from the new draft is the many topics that CMS leaves out.
In earlier parameters drafts, for example, CMS set strict translation standards for ACA public exchange programs and exchange plan issuers. The agency established elaborate rules for handling agents accused of wrongdoing, and it tinkered with the open enrollment period starting dates and ending dates.
In the new parameters draft, CMS ignores most of the parameters it has already established. It looks, for example, as if the open enrollment period for 2019 could start Nov. 1, 2018, and end Dec. 15, 2018.
2. Agents and broker auditors
HealthCare.gov managers have tried to attract agents and brokers by establishing a direct enrollment program that will let HealthCare.gov agents’ sell HealthCare.gov plans, with premium subsidies, through their own websites, without having to pass the clients over to HealthCare.gov. For 2018, agents and brokers participating in that program are supposed to get themselves audited by HHS-approved auditors.
In the new parameters draft, CMS proposes letting agents and brokers choose any auditor that appears to meet HHS requirements. Would-be auditors that have experience in areas such as health data security compliance may be able to provide the audits without getting approved by HHS. The auditors’ employees would still have to go through annual HHS training programs.
Navigators are supposed to help consumers understand the ACA exchange system but are not actually supposed to recommend specific plans.
Some agents and brokers have developed good relationships with local navigators. Other producers resent navigators and believe that navigators perform functions that should be performed only by licensed agents or brokers who have gone through a state insurance license screening and testing process and have proper errors and omissions insurance.
Navigators, for their part, have faced headaches of their own: They got into the exchange business to be helpful, low-key guides, but, now, exchange program managers want them to send in large numbers of applications. HealthCare.gov managers they have tied grants for the 2018 navigators to the navigators’ 2017 application activity levels.
CMS has required each state exchange to have at least two navigators, with one being a community- and consumer-focused nonprofit group. CMS has also required a navigator to have a physical presence in the markets it serves.
In the new parameters draft, CMS says that, starting in 2019, it may require an exchange to have just one navigator, and that it might eliminate the requirement that a navigator have a physical presence in each market it serves.
An exchange could still have two or more navigators, and it could still require navigators to have a physical presence in the markets served, but that would be up to the exchange managers, officials say.
A navigator would still have to be able to provide face-to-face help for consumers, but it could, for example, provide that face-to-face help through alliances with other organizations, officials say.