News | Health Plan Payment and Reimbursement

Oct. 28-Nov. 2: As Open Enrollment Looms, Individual-Market Changes Coming

News | Health Plan Payment and Reimbursement

Oct. 28-Nov. 2: As Open Enrollment Looms, Individual-Market Changes Coming

Oct. 25—Next week’s start of open enrollment for the individual health insurance marketplaces comes as the Trump administration moves forward with an overhaul.

The expanded waiver authority widens the definition of coverage to include more types, such as short-term plans.

Oct. 25—Next week’s start of open enrollment for the individual health insurance marketplaces comes as the Trump administration moves forward with an overhaul.

Open enrollment for 2019 federal marketplace coverage starts Nov. 1 and runs through Dec. 15 this year.

The Centers for Medicare & Medicaid Services (CMS) and the Treasury Department recently issued new guidance allowing states to submit waivers to move their individual-insurance markets “away from the one-size-fits-all rules and regulations imposed by the Affordable Care Act (ACA) and [to] increase choice and competition within their insurance markets,” according to a release.

The guidance, which goes into effect immediately but is subject to a 60-day public comment period, will broaden the options for states under ACA 1332 waivers.

New waivers, said CMS, should aim to:

  • Provide increased access to affordable private-market coverage
  • Encourage sustainable spending growth
  • Foster state innovation
  • Support and empower those in need
  • Promote consumer-driven health care

The new approaches must remain with the ACA’s “guardrails,” which ensure that people retain access to coverage that is at least as comprehensive and affordable as they could have without the waiver, covers as many individuals, and is deficit-neutral to the federal government.

New Options

The expanded waiver authority widens the definition of coverage to include more types, such as short-term plans. It allows states to consider improvements in comprehensiveness and affordability for state residents as a whole, instead of the prior focus on specific populations.

The new waiver authority will allow states to use the federally operated marketplaces to implement “new models,” according to the release.

CMS plans to issue soon “waiver concepts to help spur conversations and ideas with states, and illustrate how states might take advantage of this new opportunity to move beyond the ACA.” 

Governors also will face less restrictive requirements regarding legislative approval of their waivers. Instead, existing state legislation that provides statutory authority to enforce ACA provisions and their state’s Medicaid plan, combined with state regulations or an executive order, may satisfy the requirement.

The expanded waivers primarily aim to lower insurance costs and increase options, said administration officials. They are needed because 28.5 million Americans remain uninsured.

“In many cases, they face a stunning choice: pay the equivalent of a second mortgage for health insurance, or roll the dice hoping a health catastrophe doesn’t strike while they live without the protection of health insurance,” Seema Verma, administrator of CMS, wrote in a recent blog post.

The new flexibility follows previous efforts that had similar goals and resulted in expanded use of association health plans and short-term plans. In reaction, some states have enacted laws to bar or limit those types of plans.

Recent Trends

The changes are likely to increase the number of 1332 waivers beyond the seven that have been granted so far.

The Trump administration said the earlier waiver authority was limited to reinsurance requests, which constitute six of the approved waivers. The administration deemed three other state waiver requests as incomplete, and three more were withdrawn.

In contrast, 45 Medicaid waivers have been approved for 37 states. Another 28 from 26 states are pending.

The increased 1332 waiver authority comes amid the first reduction in average premiums since the government-run marketplaces were launched in 2014. CMS recently revealed that the average premium for the second-lowest-cost silver plans for the 2019 coverage year will decline by 1.5 percent.

Average individual-market annual premiums for plans sold in the federally operated marketplace more than doubled from $2,784 in 2013 to $5,712 in 2017, according to CMS. Similarly, from 2017 to 2018, average premiums for the second-lowest-cost silver plan increased by 37 percent, following a 25 percent increase from 2016 to 2017.

A Trump administration official recently told a national gathering of health insurance companies that 24 new insurers will join the ACA marketplaces in 2019, while 29 existing insurers will expand their offerings. The number of participating insurers had been in a steady decline since 2015.

Administration officials credited the 2019 plan premium reductions and increased insurer participation to actions the administration has taken to stabilize the market. Critics have maintained that the administration is undermining the market, regardless of the drop in premiums.

“But our work isn’t done,” Verma wrote. “Premiums are still much too high and choice is still too limited.”

The administration is betting states can fix that.

Sunday, Oct. 28

LeadingAge Annual Meeting & EXPO, Philadelphia (through Oct. 31). Learn more.

Monday, Oct. 29

Webinar by the Agency for Healthcare Research and Quality (AHRQ) titled “Recruitment Webinar for the AHRQ Safety Program for Improving Surgical Care and Recovery.” Learn more.

Webinar for the Centers for Medicare & Medicaid Services’ (CMS’s) Regions V, VI, and VII titled “Omnibus on Burden Reduction.” Learn more.

Webinar by America’s Health Insurance Plans (AHIP) titled “Embracing the Evolution of Health Care Technology.” Learn more.

Tuesday, Oct. 30

Webinar by HFMA titled “Developing a Pricing Strategy for the 2019 CMS Transparency Requirement.” Learn more.

Webcast by CMS titled “Physician Compare: Preview Period and Public Reporting.” Learn more.

Webinar by AHIP titled “Rethinking Post-Acute Care to Drive Value.” Learn more.

Web conference by the Advisory Board titled “Cybersecurity: Why the whole C-suite is accountable.” Learn more.

Webinar by the American Hospital Association (AHA) titled “Market Trends in Bundled Payments - Part 1” Learn more.

Webinar by CAQH CORE titled “Update on CORE's recent activities related to industry development and/or implementation of healthcare operating rules.” Learn more.

Webinar by the Medical Group Management Association (MGMA) titled “The Value of Group Purchasing to Reduce Cost.” Learn more.

CHIME18 Fall CIO Forum, San Diego (through Nov. 2). Learn more.

Webinar by the American Bar Association titled “Antitrust Developments in Health Care Labor Markets.” Learn more.

Wednesday, Oct. 31

Long-term care informational webinar by AHRQ titled “Safety Program for Improving Antibiotic Use.” Learn more.

Webinar by AHA titled “AI-Powered Precision Health: Shaping the Future of Health Care.” Learn more.

Webinar by MGMA titled “The Power of Patient Engagement to Improve Patient Safety.” Learn more.

Thursday, Nov. 1

Launch of open enrollment for 2019 coverage in the federal ACA marketplaces (through Dec. 15). Information for hospitals.

Deadline for submission of Second Quarter (2Q) 2018 Population and Sampling data for hospitals participating in the Medicare Hospital Inpatient Quality Reporting (IQR) Program. Learn more.

Meeting of the Medicare Payment Advisory Commission, Washington, D.C. (through Nov. 2). Learn more.

Webinar by the National Business Group on Health titled “Large Employers' Health Care Strategy in 2019.” Learn more.

Webinar by AHIP titled “It’s in the Stars: 2019 CMS Star Ratings.” Learn more.

Webinar by AMA titled “All of Us Research Program.” Learn more.

Webinar by AHA titled “Market Trends in Bundled Payments - Part 1” (repeat event). Learn more.

Long-term care informational webinar by AHRQ titled “Safety Program for Improving Antibiotic Use”” (repeat event). Learn more.

Web conference by the Advisory Board titled “Make Your Cultural Aspiration the ‘New Normal.’ Learn more.

Friday, Nov. 2

AAMC Annual Meeting, Austin (through Nov. 6). Learn more.

About the Authors

Rich Daly

is a senior writer/editor in HFMA’s Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare

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