HHS Releases Final Rule for Standard Plan Designs and Network Adequacy Requirements

The Department of Health and Human Services (HHS) finalized several benefit and payment regulatory changes for 2017, including: establishing voluntary standard cost sharing designs for bronze, silver, and gold plans; establishing a 1.5% fee in 2017—expected to increase to 3% over time—for states to lease HealthCare.gov eligibility and enrollment functionality; and allowing certain non-grandfathered insurance plans to remain non-compliant with ACA rules through the end of 2017. The final rule does not finalize a proposed federal default standard for time and distance network adequacy requirements. The rule also delays the requirement that insurers provide protections against excessive cost sharing for services rendered by out-of-network providers in in-network facilities until 2018. Finally, the open enrollment period for benefit years 2017 and 2018 has been finalized to run from November 1 to January 31, while for benefit years thereafter, open enrollment will run from November 1 to December 15.

CMS Announces New Special Enrollment Period Confirmation Process

A new Special Enrollment Confirmation Process is being implemented in HealthCare.gov states for some consumers applying for coverage or changing their health plan outside of open enrollment period. The requirements apply to special enrollment periods (SEPs) due to: loss of minimum essential coverage; permanent move; birth; adoption; placement for adoption; placement for foster care or child support or other court order; or marriage. Documentation verification will be implemented over the next several months. In the meantime, SEP applicants will be required to acknowledge that verification documents will be requested of them at a later date. In addition, SEP application questions will also have further explanations regarding what qualifies as a loss of minimum essential coverage or a permanent move. CMS has requested comments from consumer advocates, insurance companies and other stakeholders on the new process, which will help inform implementation. CMS recently eliminated six SEPs in an effort to stabilize the insurance risk pool in response to insurers' concerns over the eligibility of and utilization by SEP enrollees.

GAO Finds HealthCare.gov Fraud Risk Inadequately Managed

A Government Accountability Office (GAO) report found that CMS did not appropriately analyze available HealthCare.gov data to identify fraud vulnerabilities during the first open enrollment period in 2013. GAO reviewed HealthCare.gov's processes for determining and validating eligibility for enrollment and income-based subsidies and found that CMS did not have an effective process for resolving inconsistencies for individual Marketplace applicants. The report makes eight recommendations, including that CMS should: consider analyzing verification system outcomes; take steps to resolve inconsistencies in applicant data; and conduct a risk assessment for potential fraud in Marketplace applications. The Department of Health and Human Services concurred with the report's recommendations and noted that some are already being implemented, such as daily updates to call center representatives about inconsistent documentation.

OIG Report Examines HealthCare.gov's Post-Launch Recovery

CMS and its contractors were quick to take corrective actions following the failed launch of HealthCare.gov by adopting a "badgeless" culture wherein CMS staff and contractors worked as a team regardless of job title or employer, and by "ruthlessly" prioritizing achievable goals over less essential ones, according to a new Office of Inspector General (OIG) case study. OIG reviewed HealthCare.gov implementation and execution from the ACA's passage in 2010 through the second open enrollment period and found that the federal Marketplace faced a high risk of failure due to technical complexity, a fixed deadline, and a high degree of uncertainty about mission, scope, and funding. Despite these risks, CMS was able to recover HealthCare.gov to accommodate a high volume of consumers within two months of the launch. CMS concurred with the OIG's call for "continued progress" in the following areas: leadership, alignment, culture, simplification, integration, communication, execution, oversight, planning and learning.

20 Million Fewer Are Uninsured Since ACA Implementation

The number of uninsured fell by 20 million since the ACA was passed in 2010, lowering the percentage of people without health coverage from a high of 16% in 2010 to 9.1% at the end of 2015, according to data released by the Centers for Disease Control and Prevention's National Center for Health Statistics (NCHS). Both public and private coverage rates increased and the percentage of people ages 18-65 with private health coverage reached the highest it has been since 2005 (70%). People are also less frequently foregoing needed medical care due to cost; 6.9% went without care in 2010 compared to 4.6% in 2015, which is the lowest rate since 2000. NCHS also found that the percentage of people with a usual place to go for care has risen steadily between 2010 and 2015, from 85.4% to 87.8%.