CMS Issues Final Rule to Increase Choices and Encourage Stability in Health Insurance Market for 2018

President Donald Trump’s administration has formally adopted regulations that could help increase the stability of the individual major medical insurance market, and the Affordable Care Act exchange system, in 2018.

One big change in the new package of regulations will move the end of the open enrollment period for 2018 individual major medical coverage to Dec. 15, from Jan. 31, 2018.

The Centers for Medicare & Medicaid Services (CMS), the agency that put out the packet of regulations, also has made a final decision to:

  • Require all consumers who apply for “special enrollment periods,” or exceptions to the usual individual major medical open enrollment period deadline, through to provide documents showing they qualify for SEPs before they get health coverage in place.
  • Let states that have shown they take evaluating health provider networks seriously continue to set provider network adequacy standards for the exchange plans in their states.
  • Give exchange plan issuers a little more wiggle room when it comes to meeting ACA health plan actuarial value standards.

CMS began formal work on the new regulations after Trump took the oath of office, but they appear to reflect changes that CMS officials began to develop while Barack Obama was still president.

CMS assumes in the regulations that existing laws, regulations and batches of informal guidance related to the ACA exchange system and ACA individual major medical rules will stay in place.

The ACA has blocked health insurers from considering personal health factors other than age and location when issuing coverage, pricing coverage or designing benefits since Jan. 1, 2014.

Regulators, insurers and ACA exchange plan managers developed the open enrollment period calendar, or limits on when people can buy individual health coverage without showing they have what the government classifies as a good reason to do so, to discourage healthy people from waiting until they get sick to pay for coverage.

In the past, health insurers and patient advocacy groups have clashed over whether some consumers were abusing the system in ways that helped those consumers wait until they got sick to pay for coverage.

CMS officials said in the introduction to the new final regulations that they believe the shorter 2018 enrollment period and tighter SEP eligibility verification rules will improve the quality of the risk pool and help persuade insurers to stay in the individual market.

Seema Verma, the newly confirmed Trump CMS administrator, said in a statement included with the CMS announcement about the new final regulations that CMS is “committed to ensuring access to high quality affordable health care for all Americans.”

The changes made in the new regulations “will help stabilize the individual and small-group markets,” Verma said. “They are not a long-term cure for the problems that the Affordable Care Act has created in our health care system.”

CMS officials acknowledged in a discussion of the new regulations that the SEP verification requirements could cause problems for some consumers who cannot obtain the documentation required.

“Therefore, we will permit consumers to send us the details about their qualifying event with an explanation of why they are unable to submit requested documentation, and we will take their letters into consideration when deciding whether to exercise reasonable flexibility,” officials said.

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