HHS Moves to Help High-Risk Enrollees, Stabilize Obamacare Markets

Stay ahead of developments in federal and state health care law, regulation and transactions with timely, expert news and analysis.

By Sara Hansard

Insurers will get more help covering high-risk Obamacare enrollees under a rule finalized Dec. 16.

The Department of Health and Human Services released the final 2018 Notice of Benefit and Payment Parameters rule (RIN:0938-AS95, RIN:0938-AS87), which implements a wide range of major policies for the Affordable Care Act health insurance exchanges. It is scheduled to be published in the Federal Register Dec. 22. The regulations are effective Jan. 17, 2017.

The HHS issued the annual rule earlier this year than in the past to help stabilize the exchange markets. Most health insurers have lost money on plans since the ACA exchanges began in 2014 as a sicker population has signed up than was originally expected.

Deadline Extended

In addition to finalizing the exchange rule, the HHS Dec. 15 extended the deadline for signing up for Jan. 1 coverage on the federal HealthCare.gov exchange from Dec. 15 until Dec. 19. The HHS said it was doing so “because of extraordinary demand at HealthCare.gov and our Marketplace Call Center.” The federal exchange will operate in 39 states in 2017.

On Dec. 14 the Centers for Medicare & Medicaid Services said that as of Dec. 10 more than 4 million people had selected plans on HealthCare.gov since open enrollment for 2017 began Nov. 1. That number included 1.1 million new consumers and 2.9 million renewing coverage. Dec. 12 and Dec. 13 “have been two of the biggest days of any Open Enrollment, with more than 700,000 sign-ups,” the CMS said in that notice.

The CMS included a number of market stabilization measures in the rule issued Dec. 16.

“The Administration will leave the Marketplace on a stable path that, when fully implemented, will ensure quality coverage is available for all Americans well into the future,” acting CMS Administrator Andy Slavitt said in a release.

Transparency for Dialysis Patients

The rule included new requirements to improve transparency for patients getting treatment at dialysis facilities paid by third parties, which the CMS said was in response to concerns that some dialysis facilities were steering Medicare- and Medicaid-eligible patients toward individual market coverage that paid higher reimbursement rates and was “often not in the patient’s best interest.”

It also included a pilot program requiring consumers who enroll outside of normal open enrollment periods to submit more documentation verifying their eligibility to do so.

Many health plans, especially small, new health plans, have complained that the ACA risk adjustment program favors established insurers, who receive payments to cover sicker patients. The CMS said it is “creating a next generation risk adjustment model” addressing four areas.

New Rules to Improve Risk Adjustment

The new rule will account for people who had a marketplace plan for less than 12 months, who insurers say tend to have higher medical claims than people who stay enrolled all year. The new model will use prescription drug data to help account for sicker members, which most health insurers supported. The rule also better accounts for the risk of high-cost patients, and it improves compensation for healthier members, the CMS said.

The rule also broadens the availability of plans that offer standardized benefits by accommodating state cost-sharing rules, the CMS said. Health insurers had opposed the standardized plans, which HealthCare.gov began offering in 2016, arguing that increasing use of standardized plans limits their ability to offer affordable coverage.

The CMS also released the final 2018 annual letter to issuers, which providers operational and technical guidance to issuers selling plans in the federal marketplace.

To contact the reporter on this story: Sara Hansard in Washington at shansard@bna.com

To contact the editor responsible for this story: Kendra Casey Plank at kcasey@bna.com

For More Information

Copyright © 2016 The Bureau of National Affairs, Inc. All Rights Reserved.

Request Health Care on Bloomberg Law