CMS' new proposal to shore up the Affordable Care Act (ACA) marketplaces signals that federal officials have heard concerns that not enough has been done to prevent adverse selection or share risk for the sickest patients who gained coverage under the ACA.
After 2 national insurers largely retreated from the health insurance marketplaces set up under the Affordable Care Act (ACA) in the past year, CMS issued new payment parameters for 2018, more than 2 months before its typical November release. The announcement is a signal that federal officials are listening to concerns that not enough is being done to compensate insurers for very sick patients who have gained coverage under the ACA.
The most eye-catching change for 2018 would allow health plans to add prescription drug claims data to their calculations on the health status of enrollees. CMS uses this to distribute government assistance under its risk adjustment programs.
“We are proposing today a set of critical actions based upon our first 3 years’ experience that, if finalized, would improve how consumers and health plans interact with the Marketplace,” Andy Slavitt, acting administrator of CMS, said on August 29, 2016. “These proposals help fulfill the promise that affordable, quality health coverage can be provided to everyone who needs it.”
Insurers have repeatedly complained that not enough young consumers are signing up for health plans on the exchanges, and when they do, it’s often because they are already sick. Then, once their medical issue is resolved, many drop their coverage, thus burdening the plan with costs and no more premium dollars to cover them. While the administration has insisted recently that the risk profile on the exchanges is improving, Slavitt said the changes in the proposed new rule are designed to address these problems:
For consumers, the proposal includes additional changes to make it easier to compare plans. The proposal promotes the use of simplified plan options, while incorporating changes to reflect rules passed in several states that limit cost sharing.
The proposal also calls for smoothing premium increases that occur as children transition from adolescence to young adulthood, which would avoid premium spikes that can occur when an adult child reaches age 21.
Finally, the proposal seeks to codify special enrollment periods, “to ensure the rules are clear and limit abuse,” according to a CMS fact sheet. The agency invites ideas on how to prevent abuse by those who are ineligible for mid-year enrollment, to avoid the adverse selection that experts say has led to losses.
What We’re Reading: Abortion Privacy Rules; Alzheimer Drug Hurdles; Nursing Home Staffing Overhaul
April 23rd 2024New health privacy rules aim to protect patients and providers in an evolving abortion landscape; some physicians express concerns about efficacy, risks, and entrenched beliefs in treating Alzheimer disease; CMS addresses longstanding staffing deficits in nursing homes.
Read More
Navigating Health Literacy, Social Determinants, and Discrimination in National Health Plans
February 13th 2024On this episode of Managed Care Cast, we're talking with the authors of a study published in the February 2024 issue of The American Journal of Managed Care® about their findings on how health plans can screen for health literacy, social determinants of health, and perceived health care discrimination.
Listen
Drs Raymond Thertulien, Joseph Mikhael on Racial Disparities in Multiple Myeloma Care Access
December 28th 2023In the wake of the 2023 American Society of Hematology Annual Meeting and Exposition, Raymond Thertulien, MD, PhD, of Novant Health, and Joseph Mikhael, MD, MEd, FRCPC, FACP, chief medical officer of the International Myeloma Foundation, discussed health equity research highlights from the meeting and drivers of racial disparities in multiple myeloma outcomes.
Listen