/ News & Insights / CMS Releases Final Individual Market Rules for the Affordable Care Act

CMS Releases Final Individual Market Rules for the Affordable Care Act

Individual Market Rules
healthcare on April 14, 2017 - 12:20 pm in News & Insights

Late Thursday afternoon, the Trump Administration released final individual market rules hoping to stabilize the Affordable Care Act. According to the Centers for Medicare and Medicaid Services (CMS), these rules seek to improve the stability of the health insurance marketplaces and soothe insurers prior to them submitting their rates for 2018. The final rule enacts the following changes:

  • Reducing the annual open enrollment period for the marketplaces from three months to six weeks running from November 1 to December 15th. This brings the enrollment period to match the enrollment procedures for the private market and Medicare.
  • Requiring individuals who sign-up in a special enrollment period to submit supporting documents to ensure that only those who are eligible can enroll.
  • Permitting insurers to require members to pay past due premiums that may be standing when returning to the same insurer.
  • Removing the requirement that insurers issue policies that cover ab actuarial value of 60 percent, possibly requiring enrollees to pay more than the 40 percent.
  • Reverting of health plans’ network adequacy rules to prior to the ACA, meaning that the federal government no longer sets standards for whether or not a network is sufficient to meet the needs of enrollees in their area. This job will return to the states.

These rule changes are mostly enacted to “encourage individuals to maintain continuous coverage throughout the year” which will “[result] in fewer individual mandate penalties and help to lower premiums.”

These changes are receiving mixed reviews. America’s Health Insurance Plans (AHIP), a lobbying group supporting insurance carriers, is in favor of these new regulations.

“This final rule adopts some important changes that have been needed for some time in order to improve the functioning of the individual market, and we appreciate those changes,” said Marilyn Tavenner, president, and CEO of AHIP, in a statement. “Those improvements include tightening up rules for special enrollment periods, greater flexibility in product and benefit design, and simplified administrative processes.”

However, The American Cancer Society’s Cancer Action Network’s (ACS CAN) President, Chris Hansen, worries that the documentation requirement will interrupt cancer patients’ ability to receive care.

“Under the new rule, patients trying to enroll in insurance plans outside of the annual enrollment period will face strict documentation requirements. These requirements, while intended to prevent people from inappropriately enrolling in plans, have the potential to delay or interrupt cancer patients’ care. Such patients often face extenuating circumstances due to the nature of their disease and treatment, like job loss or relocation, and rely on special enrollment periods to swiftly transition coverage without interrupting care.”

Photo – Copyright: txking / 123RF Stock Photo
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