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.
CMS notes that a state can still offer two or more Navigator programs, and that it can still require some or all of the Navigator services providers to be nonprofit entities, and to have in-state offices.
“By allowing exchanges greater flexibility, each exchange will be better able to ensure that its service area can be assisted by the entity or entities that best fits the needs of its population,” officials write in a preamble to the final 2019 parameters regulations.
Some commenters told CMS that CMS should expand the role of other, non-Navigator providers of enrollment and support services, to make up for possible shrinkage in Navigator program services.
Here’s what CMS officials say about that:
“We agree that local collaboration and leveraging community partnerships can help in reaching marginalized communities. For [HealthCare.gov states], we will take these comments into consideration when drafting Navigator selection criteria for Navigator funding opportunity announcements in future years. While agents, brokers, and direct enrollment partners might in many cases not be eligible to become Navigators due to statutory limitations on Navigator eligibility at Section 1311(i)(4) of [the Patient Protection and Affordable Care Act], we also agree that agents, brokers, and direct enrollment partners can be well situated to provide enrollment assistance or remote services to consumers, and we intend to continue to work with these stakeholders to ensure consumers in [HealthCare.gov states] have access to a range of enrollment assistance, including Navigators.”
3. Individual major medical plans will still have to meet ACA essential health benefits (EHB) package requirements that are similar to the current EHB requirements.
The ACA EHB section requires all individual major medical plans — except for catastrophic plans available only to young purchasers and to high-income purchasers — to cover at least about 60% of the actuarial value of a benefits package that includes 10 types of critical benefits, such as benefits for physician services; hospital care; prescription drugs; rehabilitative services; and habilitative services, or services aimed at people born without typical abilities, such as the ability to walk, or the ability to learn at a typical level.
In the past, the federal government let a state base its EHB package on the benefits offered by 10 different types of plans offered in that state.
Starting in 2019, CMS will let a state adopt another state’s EHB package, or get physician services benefits standards from one existing plan, hospital benefits standards from a second plan, and habilitative services benefits standards from a third plan.
When CMS proposed the EHB benchmark rule change, back in November, some commenters complained that CMS would be letting states water down their EHB requirements.
CMS officials argue in the parameters document preamble that they’re simply giving state officials a more flexible way to apply the existing EHB requirements.
“We believe that states should have additional choices with respect to benefits, which may foster innovation in plan design and greater access to coverage, and provide states with a mechanism for affecting affordability,” officials write.
Taken as a whole, all EHB requirements together should keep states from imposing EHB requirements that are either too lean or too rich, officials say.
— Read ACA Definitions: Enrollment Period Basics on ThinkAdvisor.