Apr 18, 2018
CMS published a final rule April 9 that generally gives states more power to regulate their insurance markets. However, there are more restrictions when it comes to the advanced premium tax credit. The rule requires Exchanges to discontinue tax credits for enrollees who fail to file taxes and reconcile past advanced premium tax credits, even if the Exchange does not first send a notice directly to the tax filer. The final rule requires Exchanges to implement stronger checks to verify that applicants actually earn the income they claim to qualify for the tax credits.
Medical Loss Ratio (MLR)
tates can request reasonable adjustments to the MLR standard if they demonstrate that a lower MLR could help stabilize the individual insurance market. The final rule also reduces reporting burdens for insurers on quality improvement activity.
2019 Out-Of-Pocket (OOP) Maximums
The 2019 OOP maximums increase to $7,900 for individual coverage and $15,800 for family coverage. These coverage limits apply to all non-grandfathered plans, regardless of size or funding type.
The Small Business Health Options Program (SHOP) The final rule allows SHOPs to eliminate the online enrollment process. Employers could enroll directly with an Exchange-registered agent or broker.
Special Enrollment Periods (SEPs) Pregnant women could qualify for a loss-of-coverage SEP upon losing access to care for their unborn child under the Children’s Health Insurance Program (CHIP). Consumers who lived in a service area without any qualified health plans through an Exchange would be exempt from the prior coverage requirement that applies to certain special-enrollment periods.
Rate Review The rule exempts student health insurance coverage from federal rate review requirements. The final rule will make it easier for insurers to raise rates in states requiring federal rate approval. CMS widened the default threshold for rate review from 10 percent to 15 percent.
Hardship Exemption Additional guidance expands the individual mandate hardship exemptions available for 2018 for people living in states with federally-facilitated Marketplaces. Individuals who live in counties with no issuers or only one issuer will qualify for a hardship exemption from paying the ACA's penalty for not having coverage.
Transitional Policies CMS will extend the transitional policy for one more year. This policy allows for the transition to fully Affordable Care Act compliant coverage in the individual and small group health insurance markets until 2019.
Essential Health Benefits (EHB) For plan years beginning on or after January 1, 2020, CMS is giving states more flexibility in selecting their EHB-benchmark plans. Instead of being limited to 10 options, states can choose from the 50 EHB-benchmark plans or select specific EHB categories, such as drug coverage or hospitalization. A States would be able to build their own set of benefits as their EHB-benchmark plan, subject to certain requirements.
Qualified Health Plan (QHP) Certification Standards The final rule gives states additional authority to review of network adequacy. It eliminates the meaningful difference requirement for qualified health plans, giving insurers more flexibility in designing plans.
Exemptions When there is no Bronze level plan available in the service area, exchanges will be able determine whether there is a lack of affordable coverage based on projected income using the lowest cost metal level plan offered through the Exchange.
