Trump Administration Proposes Insurer-Friendly Rule Modifying Exchanges under the ACA

Health Care   |   February 16, 2017
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Less than three weeks after our last article involving healthcare under the Trump Administration, the Centers for Medicare and Medicaid Services Department of Health and Human Services (“HHS”) has released its first proposed rule (the “Proposed Rule”).  The goal of the Proposed Rule appears to be to lessen the burden on insurers while the administration develops a full replacement for the Affordable Care Act (“ACA”).  The short 20-day comment period indicates that the administration has a desire to implement changes quickly.

According to an HHS press release, the Proposed Rule aims to “stabiliz[e] the individual and small group health insurance markets” by shortening the 2018 enrollment period, lowering insurers’ minimum standards for care to qualify for the exchanges and forcing beneficiaries to pay back owed premiums prior to obtaining coverage for the next year.  Not all of these changes step from new administration; some are from an Obama administration effort from August 2016 to alleviate certain imbalances in the exchanges. 

2018 Enrollment Period To Be Shortened

Under the Proposed Rule, the 2018 open enrollment period would be reduced from three months to six weeks.  HHS anticipates that an earlier end date for open enrollment would ensure all consumers receive a full year of coverage, decrease the burden on insurers and the exchanges of processing enrollment, and improve the risk pool by “reduc[ing] opportunities for adverse selection by those who learn they will need services in late December or January.” 

The Proposed Rule also proposed creation of a Special Enrollment Confirmation Process by which consumers enrolling through special enrollment periods must provide certain documentation.  According to insurers, this change, which is expected to delay enrollment for 650,000 individuals while their eligibility is verified, is necessary to ensure consumers do not enroll solely when they need costly medical services and unenroll after such services have been provided.

Minimum Standards of Care to be Lowered

The language contained in the Proposed Rule also relaxes the minimum standards for coverage allowing insurers to cover slightly fewer areas of health and still have their plans classified at certain bronze, silver, and gold plan levels.  This change is expected to increase out-of-pocket costs for beneficiaries in the short term, but lower premiums long-term. 

The Proposed Rule will have an impact on network adequacy and access to essential community providers who serve primarily poor and underserved patient populations.  While insurers currently must meet federal and state standards relative to network adequacy, the proposal shifts this to sole state responsibility with mandatory coverage of 30% of essential community providers in a given territory reduced to 20%.

Guaranteed Availability

The Proposed Rule would allow insurers to collect premiums for prior unpaid coverage before enrolling a patient in the next year’s plan with the same issuer.

This is likely the first of many steps to alter insurance coverage and the health care landscape as a whole by the new administration.  Despite what some consider insurer-friendly changes, the uncertainty surrounding the ACA and regulation of the individual insurance market has even insurers concerned, evidenced by Humana’s recent announcement to leave the market.  It is unclear whether other organizations of Humana’s size and stature will follow suit and opt out of participation in 2018, the deadline for which is fast-approaching . 

If you have questions about these changes or other health care policy and legal changes under the Trump administration, please do not hesitate to contact a member of our health care team.

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