On February 15, 2017, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule to stabilize the individual and small group health insurance market by increasing incentives for individuals to maintain enrollment in health plans, decreasing incentives to enroll in coverage only after healthcare services are needed, and reducing the regulatory burdens for insurers participating in health insurance exchanges. According to CMS, addressing these issues will increase insurer participation in the individual and small group health insurance markets and result in more affordable coverage. If the proposed changes become finalized, CMS will issue separate guidance to update the qualified health plan certification calendar and the rate review submission deadlines for the 2018 plan year. Significant proposed changes are highlighted below.

Guaranteed Availability of Coverage

The guaranteed availability of coverage rules require insurers offering non-grandfathered health insurance coverage in individual and group health insurance markets to offer coverage to and accept every individual and employer within a state applying for health insurance coverage with certain exceptions. CMS proposes to modify its interpretation of the guaranteed availability of coverage rules for individuals with past due premiums. CMS’s current interpretation of the guaranteed availability of coverage rules requires an insurer to allow an individual to purchase insurance coverage offered by the insurer without paying past due premiums so long as the individual purchases a different insurance product offered by the insurer. Under the modified interpretation, an insurer would be allowed to attribute payments for new coverage to the past due amounts owed on any previous product offered by the insurer to the individual within the past 12 months and to refuse to provide new coverage for failure to pay premiums. This modified interpretation of the guaranteed availability of coverage rules would be subject to state law and would not keep an individual or employer from enrolling with a different insurer or keep someone other than the individual with the past due premium debt from purchasing coverage on behalf of the individual.

Open Enrollment Periods

CMS proposes to shorten the enrollment periods for plan year 2018. The open enrollment period would begin on November 1, 2017 and end on December 15, 2017. Everyone enrolling during this new open enrollment period would have an enrollment effective date of January 1, 2018.

Special Enrollment Periods

CMS proposes to increase pre-enrollment verification of eligibility by the Department of Health and Human Services (HHS) to all individuals seeking to enroll in health insurance coverage offered on federally-facility or state-based health insurance exchange through a special enrollment period beginning in June 2017. No longer would individuals qualifying for a special enrollment period due to a certain life event like losing health coverage, moving, getting married, having a baby, or adopting a child be able to self-attest to their eligibility for most special enrollment periods. Instead, an individual wanting to enroll through a special enrollment period would submit an enrollment application, select a plan, and have 30 days to provide the requested documentation showing proof of eligibility for the special enrollment period via HealthCare.gov or by mail. The individual’s enrollment status would be “pending” until verification of eligibility is complete, however, the start date of enrollment would be retroactive to the plan selection date.

Determining Levels of Coverage

The Affordable Care Act requires health insurance plans to cover a certain amount of essential health benefits for a standard population subject to a de minimis range adjustment of -2/+2 percentage points. CMS would adjust the de minimis range used to determine the level of coverage offered in individual and small group health insurance plans to a variation of -4/+2 percentage points.  For example, bronze plans offer coverage of 60 percent of essential health benefits, with 70 percent for a silver plan, 80 percent for a gold plan, and 90 percent for a platinum plan. The proposed rule would permit a silver plan to offer a coverage range of 68 – 72 percent and still qualify as a silver plan.

Network Adequacy

For the 2018 plan year, CMS would defer to states the review of the adequacy of insurer networks for certification as a qualified health plan, provided that the state has the authority and the means to assess insurer network adequacy. For states without such authority and means, CMS would either rely on an insurer’s accreditation from an HHS-recognized accrediting entity (e.g., the National Committee for Quality Assurance, URAC, and Accreditation Association for Ambulatory Health Care) or rely on the submission of an access plan by an unaccredited insurer.

Essential Community Providers

CMS proposes to change the minimum percentage of essential community providers (ECPs) required to be a part of a qualified health plan provider network to 20 percent (lowered from 30 percent) for the 2018 plan year. ECPs include providers serving predominantly low-income and medically underserved individuals. CMS also proposes to allow insurers to identify ECPs within their networks if such providers are included on the HHS ECP list or identified through the write-in process on the insurers qualified health plan application.

The proposed rule is scheduled to be published in the Federal Register on February 17, 2017. Comments to the proposed rule must be received by CMS no later than 5 pm EST on March 7, 2017.