2019 ACA Parameters Document Released by CMS

Written by Jessica Adkins

April 10, 2018

2019 ACA Parameters Document Released

The Centers for Medicare and Medicaid Services posted a new batch of regulations regarding how the Affordable Care Act’s federal marketplace (Healthcare.gov), and the individual under-age medical market will work in 2019. Healthcare.gov currently services for the web-based enrollment system for 38 states and is ran by CMS. CMS also has oversight of the locally based programs or “state-based” marketplaces in 12 states and D.C.

President Trump and Congress have been diligently attempting to provide solutions for pieces of the ACA, they feel need to be eliminated (i.e., the requirement for all U.S. citizens to have credible health coverage, the tax penalty, and subsidies.) However, only modest changes have been made to the ACA rules. None of the proposals made have received serious consideration in the past year to eliminate Healthcare.gov or the state-based marketplaces.

CMS has now completed and published work on a 523 page ACA “benefit and payment parameters” package. This package is similar to a draft the agency released in November of 2017.
Additionally, CMS also published 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.

Here’s a look at three provisions that are in the documents that could have an effect on the agents and brokers working with under-age individuals and families:

1. Getting Certified

CMS has adopted a proposal to let any competent “third-party entity” decide whether an agent is ready to sell Healthcare.gov plan coverage directly to consumers, without passing the consumers on to Healthcare.gov. In the past, agents selling on the marketplaces had to get certified by approved Health & Human Services entities. Those selling on the FFM were required to take the certification provided by the Medicare Learning Network, and while some states required the MLN certification – many state-based marketplaces developed and required their own training and certification processes to be completed. Also, most carriers required the certificate of completion because an agent was deemed “ready to sell.”

2. Competition from ACA Navigators

Navigator programs were developed to help low-income individuals and families enroll through the marketplace. In many cases, the Navigator services were nonprofit entities and were made available to individuals at an in-state office (e.g., local health departments or the Departments of Health and Human Services.) Navigators were to have a physical presence in each state.
Starting in 2019, a state-facilitated marketplace 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.

3. Essential Health Benefits

The ACA required all individual major medical plans—except for catastrophic plans—to cover about 60% of the actuarial value of a benefits package and include 10 types of “essential health benefits.” Those benefits included hospital care, rehabilitative services, ambulance services, mental and behavioral health coverage, maternity and newborn care, prescription drugs, and more. In the past, unless health plans included the essential health benefits – they were deemed non-compliant and did not fall into the category of “credible coverage.” Those enrolled in a plan that was not considered credible faced a penalty at the end of the year.

Starting in 2019, CMS will let a state adopt another state’s essential health benefits package, or get physician services benefits standards from one existing plan, hospital benefits standards from a second plan, and habilitative services benefit 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 essential health benefits 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.

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