The rule, which is largely unchanged from a proposed rule released in February, comes as insurers are weighing whether they will participate in the exchanges for the 2018 coverage year. Several major insurers—including Aetna, Humana, and UnitedHealth Group—scaled back their exchange participation for the 2017 coverage year. Further, Humana earlier this year announced that it will withdraw from all ACA exchange markets for the 2018 coverage year, and Aetna Chair and CEO Mark Bertolini and Anthem CEO Joseph Swedish separately said their companies are considering similar moves.
Final rule details
The final rule shortens by six weeks the ACA's open enrollment period for the 2018 coverage year. The open enrollment period for the 2018 coverage year will begin Nov. 1, 2017, and end Dec. 15, 2017. The open enrollment period previously was scheduled to run through Jan. 31, 2018.
CMS said the change will align the exchange market with the employer-sponsored health insurance market and Medicare.
In addition, the final rule bolsters the enrollment verification process for individuals who enroll through special enrollment periods—such as those who have moved states or lost prior insurance coverage. Current policy requires insurers to immediately begin covering individuals who sign up for exchange plans via special enrollment periods, but under the new rule, such individuals will be required to submit documentation demonstrating their eligibility. Former President Obama's administration last year began testing a similar policy but decided against fully implementing the change because of concerns it would pose a significant barrier to obtaining insurance.
Further, insurers under the final rule will be allowed to refuse to renew coverage for individuals who have missed premium payments within the past year until they make those payments.
CMS also adjusted the actuarial levels—the percentage of an individual's health care costs a plan would cover—that plans in each metal tier must meet. For instance, a silver level plan currently must cover between 68 to 72 percent of an enrollee's costs, but the final rule lowers that bottom threshold to 66 percent, meaning consumers may pay lower premiums but could face higher overall out-of-pocket costs for care, Modern Healthcare reports. Further, according to Vox, the amount of the ACA subsidies that individuals receive to help pay for their coverage could decline because their value is tied to the cost of silver level plans.
To offset some of those costs, HHS in the final rule will increase the cost-sharing reductions aimed at insurers for 2018 by between $200 million to $400 million, according to Modern Healthcare. However, Tim Jost, an emeritus law professor at Washington and Lee University, said the final rule's cost sharing provision does not bind the agency or the Trump administration to actually make the payment to insurers—a controversial question in recent days.
In addition, the final rule removes the Obama administration's network adequacy requirement, meaning insurers must meet only state requirements related to whether health insurance plans provide adequate networks of doctors and hospitals.
CMS administrator Seema Verma in a release said, "While these steps will help stabilize the individual and small-group markets, they are not a long-term cure for the problems that the ACA has created in our health care system."
The final rule has drawn mixed responses from health care stakeholders.
Insurers largely welcomed the changes, particularly those aimed at tightening special enrollment periods, but said that more must be done to address the uncertainty in the market.
For instance, Marilyn Tavenner, president and CEO of America's Health Insurance Plans, in a statement said, "This final rule adopts some important changes that have been needed for some time in order to improve the functioning of the individual market," but added that "health plans and the consumers they serve need to know that funding for cost-sharing reduction subsidies will continue uninterrupted." Without those payments, Tavenner predicted individual market premiums would rise 20 percent and more insurers would drop out of the exchanges.
Consumer advocacy groups and some health care regulators criticized the final rule, saying it will make it more difficult for people to get insurance.
Families USA Executive Director Frederick Isasi said, "The Trump Administration is going full-steam ahead with its latest effort to try and sabotage the Affordable Care Act and is making health care less affordable, less accessible and less meaningful for America's families."
California Insurance Commissioner Dave Jones said, "Like President Trump's threats to eliminate the cost-sharing subsidies, his new regulations will destabilize, rather than strengthen, the health insurance market."
American Hospital Association EVP Tom Nickels commended the Trump administration "for finalizing several policies that will help keep the marketplaces as a source of coverage for millions of Americans." However, Nickels said the group remains "deeply concerned that the most critical challenge facing the marketplaces today is unresolved: assurance that funding for cost-sharing reductions will be available to insurers" (Cancyrn, Politico Pro, 4/14 [subscription required]; Abutaleb, Reuters, 4/13; AHA News, 4/13; Dickson, Modern Healthcare, 4/13; Scott, Vox, 4/13; Pugh, Sacramento Bee, 4/13).
What does health care reform beyond the ACA look like? Join us on May 2nd
Stuart Clark, Managing Director
The first part of the Health Care Advisory Board’s latest “State of the Union” explores what the Trump administration and GOP-controlled Congress will mean for the future of coverage expansion, payment reform, and federal entitlement programs.
The presentation provides an objective analysis of the next era of health care reform, unpacking the potential futures of Medicare, Medicaid, and the private insurance market—and what those changes would mean for provider strategy. The presentation also includes a detailed assessment of the accomplishments, shortcomings, and unintended consequences of the Obama-era reforms.