Proposed Changes to Affordable Care Act Compliance by CMS
The Department of Health and Human Services, via the Centers for Medicare & Medicaid Services (CMS), proposes significant changes to the regulatory compliance requirements for the Affordable Care Act (ACA) coverage plans. Key elements of this proposal include eliminating mandatory standardized plan options and limiting the number of non-standardized plans that insurance carriers can offer in the individual market. These proposed changes are part of the Notice of Benefit and Payment Parameters for the 2027 Proposed Rule.
Insurers will have the discretion to offer plans targeting chronic and high-cost conditions, with the option to maintain current cost structures or introduce modifications. This initiative aims to reduce administrative complexity for both payers and the CMS, allowing more room for innovation in plan offerings. Moreover, the proposal anticipates a shift towards AI-driven prior authorization processes, streamlining operations.
A major update is the potential introduction of catastrophic insurance plans with terms extending up to a decade. The CMS seeks feedback on applying similar long-term structures to metal-level plans. The regulatory proposal considers adjustments in catastrophic plans’ index rates, alongside monthly prorated cost-sharing for each contract year. These plans might also leverage value-based designs for enhanced preventive care services, which could be availed before meeting deductibles.
Plan and Cost-sharing Adjustments
The proposal suggests revising cost-sharing regulations, specifically for bronze and catastrophic plans, starting in 2027. User fee rates for federally facilitated and state-based exchanges will remain at 2.5% and 2% of monthly premiums, maintaining the 2026 rates. Additionally, CMS aims to streamline agent and broker training by eliminating the need for CMS-approved vendor programs, opting instead for resources available through the Marketplace Learning Management System.
The CMS is implementing documentation mandates to verify income for consumers with household incomes below 100% of the federal poverty level, reinstating a requirement from the 2025 Marketplace Integrity and Affordability rule. A new State Exchange Improper Payment Measurement program is also proposed to assess how state exchanges distribute premium tax credits, ensuring thorough oversight and risk management.
Network Adequacy and Enrollment Innovations
CMS aims to delegate network adequacy authority back to state-based exchanges, allowing for alignment with local market and provider needs. Non-network plans could attain certification by demonstrating accessible provider pools, thereby increasing consumer choice. The proposal also suggests enhancing the risk adjustment process with a user fee of $0.20 per member per month for 2027, maintaining consistency with the previous year's rate.
Finally, a potential State Exchange Enhanced Direct Enrollment option would allow state-based exchanges to use web brokers for eligibility and enrollment functions, potentially removing the need for state-operated websites. CMS also proposes restricting routine adult dental services as elective benefits, maintaining alignment with ACA statutes. Comments are invited on altering premium payment thresholds to mitigate improper enrollment.
Industry professionals can contact the writer for further discussions and insights on these proposed changes via email at [email protected].
©2023 Healthcare Finance is a publication of HIMSS Media.