CMS.gov, April 9, 2018
Today, the Centers for Medicare & Medicaid Services (CMS) issued the HHS Notice of Benefit and Payment Parameters for 2019. The final rule will mitigate the harmful impacts of Obamacare and empower states to regulate their insurance market. The rule will do this by advancing the Administration’s goals to increase state flexibility, improve affordability, strengthen program integrity, empower consumers, promote stability, and reduce unnecessary regulatory burdens imposed by the Patient Protection and Affordable Care Act.
“Too many Americans are facing skyrocketing premiums that they can’t afford and every year consumers are faced with the threat of fewer choices. This rule gives states new tools to stabilize their health insurance markets and empower citizens to find coverage that fits their families’ needs and budgets,” said CMS Administrator Seema Verma.
The final rule issued today includes the following key provisions:
* Essential Health Benefits (EHB)
* States will also now be able to build their own set of benefits
* Qualified Health Plan (QHP) Certification Standards
Strengthening Program Integrity
* Risk Adjustment
* Advanced Premium Tax Credit (APTC) Program Integrity
* Special Enrollment Periods (SEPs)
* Medical Loss Ratio (MLR)
Reducing Unnecessary Regulatory Burden
* Small Business Health Options Program (SHOP)
* Rate Review
By Don McCanne, M.D.
The Trump administration is continuing its efforts to undermine the policies established by the Affordable Care Act. That would not be so bad if they were replacing it with a much better program such as an Improved Medicare for All. But no, just the opposite. They are doing what Congress failed to do and that is inflict as much damage as they can administratively. What is particularly offensive is their glowing rhetoric using terms that dishonestly imply that they are greatly improving the program.
The provisions that are being changed are listed above, and they are briefly described in the press release available at the link. A couple of examples can give you an idea of what they are doing.
ACA requires ten specific essential health benefits in the exchange plans, but the rule released allows much more flexibility in selecting the essential benefits. In a press call, CMS Administrator Seema Verma said that they wanted to allow insurers leeway to “create plans that more directly address the needs of citizens and not a one-size-fits-all D.C. mandate.” Of course, the problem with a menu of benefits is that nobody really knows what their medical needs will be next year. Benefits need to be comprehensive for everyone.
They say they would improve affordability by allowing an exemption when it is determined that coverage is not affordable based on projected income using a higher metal level plan when no bronze plan is available in the service area. Maybe it is sort of true that not buying insurance improves affordability of the exchange plans, but it sure plays havoc with affordability of health care when you are uninsured.
They are changing risk adjustment to reduce the burden on issuers, providing states “with the flexibility to request a reduction to the otherwise applicable risk adjustment transfers in the individual, small group or merged market by up to 50 percent beginning with the 2020 benefit year, which may be helpful in attracting and retaining insurers and more precisely accounting for relative risk differences in the state market.” They continue to take good care of the private insurers, but when insurers benefit financially, patients lose.
The medical loss ratio (MLR) represents the percentage of premium dollars that are paid out for health care. The new rule “allows states to request reasonable adjustments to the MLR standard for the individual market if the state shows a lower MLR standard could help stabilize its individual insurance market.” Again, this takes good care of the insurers by allowing them to spend even less than the current 80 percent requirement on health care, and, again, the patients lose.
Currently insurance premium rate increases over 10 percent must be submitted for review. The new rule changes the threshold to 15 percent. Allowing unchallenged premium increases of 15 percent year after year also takes good care of the insurers, but not so good for those paying the premiums, whether directly or through taxes.
The winners? Insurers and conservatives who want to reduce the role of government in the financing of our health care. The losers? Patients and taxpayers. That’s not good.
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