CMS Proposes Rule on PPACA Market Stabilization

On Feb. 15, 2017, CMS issued a proposed rule for 2018, which proposes new reforms to assist with the stabilization of the individual and small group health insurance markets.

The goal is to help protect patients participating in the individual and small group health insurance markets while future reforms are being employed. Ultimately, the hope is that this will provide more flexibility to states and insurers, and give patients access to more coverage options. That said, the proposed rule would make changes to certain exchange standards, such as special enrollment periods, the timing of the annual open enrollment period, guaranteed availability, network adequacy rules, essential community providers, the actuarial value requirements and the qualified health plan (QHP) certification timeline.

Specifically, the rule proposes a variety of policy and operational changes to stabilize the exchanges, including:

  • Special Enrollment Period Pre-Enrollment Verification: Starting in June 2017, the rule proposes to expand pre-enrollment verification of eligibility to individuals who newly enroll through special enrollment periods in exchanges using the platform. This proposed change would help ensure that special enrollment periods are available to all who are eligible for them, but will require individuals to submit supporting documentation. This will hopefully help place downward pressure on premiums, curb abuse and promote year-round enrollment. This change would be implemented in the federally facilitated and state-based exchanges using the federal platform (
  • Open Enrollment Period: For the 2018 coverage year, the proposed rule provides for a shortened open enrollment period of Nov. 1, 2017, to Dec. 15, 2017. The open enrollment period was previously set to be from Nov. 1, 2017, to Jan. 31, 2018, for 2018 coverage. This proposed change will align the exchanges with employer sponsored plans and Medicare (could simplify administration where coordination is required), and help lower prices by reducing adverse selection.
  • Guaranteed Availability: The rule proposes to address potential abuses by allowing an issuer to collect premiums for prior unpaid coverage before enrolling a patient in the next year’s plan with the same issuer. This is meant to incentivize patients to avoid coverage lapses. This will not be available to insurers in the federally facilitated SHOP and may not prevent individuals from enrolling in coverage with a different insurer.
  • Network Adequacy: The proposed rule focuses on reaffirming the traditional role of states to serve their populations in which a federally facilitated exchange is operating. In the review of QHPs, CMS proposes to defer to the states’ reviews in states with the authority and means to assess issuer network adequacy.
  • Determining the Level of Coverage: The rule proposes to make adjustments to the de minimis range used for determining the level of coverage (bronze, silver, gold and platinum) by providing greater flexibility to issuers to provide patients with more coverage options.
  • QHP Certification Calendar: In the rule, CMS announces its intention to release a revised proposed timeline for the QHP certification and rate review process for plan year 2018. The revised timeline would provide issuers with additional time to implement proposed changes that are finalized prior to the 2018 coverage year. These changes will give issuers flexibility to incorporate benefit changes and maximize the number of coverage options available to patients.

CMS is accepting comments on the proposed regulations through March 7, 2017. Although this rule mostly affects the exchanges and insurers offering coverage on the exchange, employers should familiarize themselves with the portions of the rule surrounding special enrollment verification and the open enrollment period.

Market Stabilization Proposed Rule »