The Centers for Medicare and Medicaid Services has posted a new batch of regulations and other documents explaining how the Affordable Care Act public exchange program, and the individual major medical market, will work in 2019.
The ACA public exchange system gives private health insurers a way to sell somewhat standardized health insurance plans to consumers directly through the web, and to give the purchasers access to the ACA advance premium tax credit subsidy program.
CMS, a division of the U.S. Department of Health and Human Services (HHS), runs HealthCare.gov. HealthCare.gov is a web-based system that provides ACA public exchange enrollment and account administration services for 38 states.
CMS also oversees the locally based programs that provide ACA public exchange services in 12 states and the District of Columbia.
President Donald Trump, and Republicans in Congress, have been trying to overhaul the Affordable Care Act, but, so far, they have made only modest changes in ACA rules. None of the Republican proposals that received serious consideration in Congress in the past year would have eliminated either HealthCare.gov or the state-based ACA public exchange programs.
CMS has now completed work on a 523-page ACA “benefit and payment parameters” package. The package is similar to a draft the agency released in November.
CMS has also published other, related documents, including a ruling that exempts failed health plans from the ACA health plan risk-adjustment program, and a guide for states that want to know how to handle ACA health insurance rate increase reviews.
For insurance agents and brokers, one of the most interesting thing about the documents may be something that’s missing: any requirements for insurers to pay commissions or fees to agents or brokers, or even to make good on the promises made in agent or broker contracts.
Here’s a look at three provisions that are in the documents that could have an effect on the agents and brokers still trying to meet clients’ individual major medical needs.
1. Getting certified to sell HealthCare.gov plans could be slightly easier.
CMS has adopted a proposal to let any competent “third-party entity” decide whether an agent or broker is ready to sell HealthCare.gov plan coverage directly to consumers, without passing the consumers on to HealthCare.gov. In the past, HealthCare.gov agents had to get themselves certified by entities approved by HHS.
2. Competition from ACA Navigators may shrink.
The architects of the ACA public exchange system tried to create an alternative to traditional health insurance distribution systems, by requiring each state’s exchange program to offer at least two types of “Navigators,” or exchange system ombudsmen: Each state has had to offer residents access to at least two separate Navigator entities, including at least one nonprofit entity.
Each Navigator services provider had to have a physical presence in the state.
Starting in 2019, a state exchange program will have to have just one Navigator, and it can choose whether the Navigator is a for-profit entity or a nonprofit entity, or whether the entity has a physical presence in the state or provides all services through the telephone, or through the web.