AOTA Comments on Annual ACA Marketplace Payment Rule
The Notice for Benefit and Payment Parameters for 2020 (NBPP 2020) was released on January 17th, 2019, by the Centers for Medicare & Medicaid Services (CMS). The NBPP is an annual set of regulations that defines the parameters for Affordable Care Act (ACA) Exchange operation. Read the proposed rule.
Fortunately, nothing proposed in the NBPP 2020 directly affects occupational therapy provision of services. Still, a few pertinent changes are considered—mainly: auto-re-enrollment, silver loading, the premium adjustment factor, and web broker modifications—that have the potential to erode health insurance coverage.
EHB Benchmark Changes
The NBPP 2019 enabled states to change their EHB benchmark plans each year. The options were to (1) keep their current benchmark plan, (2) copy another state’s plan, (3) replace one or more EHB categories with the same categories of benefits from another state’s plan, or (4) choose a new set of benefits. AOTA’s concern last year was that states intending to change or replace their EHB categories could reduce rehabilitative and habilitative services. Fortunately, this did not occur, but these options are still available for the 2020 plan year. The deadline for states to submit proposed EHB benchmark plan changes to CMS is May 6th, 2019.
Auto Re-enrollment
Consumers who enrolled in ACA plans have not been required to actively re-enroll in their plan each year because auto-re-enrollment has been standard practice. CMS is not seeking to remove auto re-enrollment for 2020, but requests comment on whether to remove this feature in the future. AOTA opposes removal of auto-re-enrollment, as it could lead to loss of coverage for a significant number of enrollees who are unaware of the need to sign up again every year.
Silver Loading
Initially, insurers were mandated under the ACA to provide cost-sharing reductions (CSRs) to make coverage more affordable for low-income individuals. However, in 2017 the Trump administration ended reimbursement to insurers for providing CSRs. Insurers responded by increasing the premiums on silver-level plans, which accordingly raised premium tax credits (subsidies) for enrollees because tax credits are based on the cost of a silver plan. This “silver loading” ensured that low-income individuals could still receive coverage through greater subsidization. CMS does not propose any changes for the 2020 plan year, but instead seeks comment on how to address silver loading. AOTA opposes prohibiting silver loading without reimbursement for CSRs, as this would erase the affordability benefits, causing some people to drop coverage, and raising premiums for people who stay because the risk pool would be smaller and sicker.
Premium Adjustment Factor
The premium adjustment factor is a measure of premium growth that is updated annually by CMS. The premium adjustment factor determines the rate of increase for the maximum out-of-pocket costs, employer shared responsibility payments, and eligibility for premium tax credits. CMS proposes to change the standard of calculating the premium adjustment percentage so it grows faster. This change will lead to increased premiums, lower subsidies for coverage, and greater out-of-pocket costs. CMS predicts that 100,000 people will drop from the ACA marketplace in 2020 and each subsequent year as a result of the proposed rule because it will make coverage more expensive. AOTA strongly opposes this proposed rule, as it results in fewer enrollees and higher premiums for those who stay.
Web Brokers
Consumers can enroll in ACA plans through Healthcare.gov or via direct enrollment on an off-Exchange website with a web broker. Web brokers are prohibited from making recommendations for ACA plans that can compensate them via the plan issuers; however, they can make implicit recommendations. For example, a web broker could place all the ACA plans that do not compensate them near the bottom of the web page. In addition, web brokers are not required to facilitate direct enrollment in all of their listed ACA plans, but they are required to provide a disclaimer and link to the Exchange for any non-facilitated plans.
The following are further regulatory changes proposed by CMS in the NBPP 2020. AOTA did not comment on these changes, but recognizes the importance of their impact on enrollees and ACA operation for 2020.
Discriminatory Benefit Design and Opioid Treatment
CMS encourages insurers to provide coverage for medication-assisted treatment (MAT) to individuals with opioid use disorder. They remind insurers that excluding types of drugs when used for MAT while allowing them for other uses can be perceived as discriminatory.
Abortion Coverage
CMS proposes that insurers offering abortion services in their plans must offer at least one “mirror plan” that does not cover abortion services.
Prescription Drug Changes
CMS proposes that insurers should be enabled to make mid-year formulary changes to replace a brand name drug with a generic equivalent of the drug. Insurers would be required to inform all enrollees 60 days prior to substitution. When a plan covers both the brand name and generic option, insurers could opt to treat only the generic as an EHB, meaning premium subsidies and caps on out-of-pocket spending wouldn’t apply to the brand name.
Navigators
CMS proposes to streamline their required 20 training topics into four categories and remove the requirement that navigators provide post-enrollment assistance to consumers.
Special Enrollment Period (SEP)
CMS proposes to add a special enrollment period (SEP) for individuals enrolled in off-Exchange plans who experience an unexpected decrease in income.
Although nothing proposed in the NBPP would directly affect occupational therapy coverage, several items have the potential to reduce enrollment in comprehensive health insurance. Therefore, AOTA remains committed to monitoring federal and state legislation and regulations. Watch this blog for an update when the final rule is released.
Andrew Wagner is completing his doctoral experience with AOTA’s State Affairs and Health Policy Department.