Changes Needed in Regulatory Plans for Health Insurance Marketplace, ACP Tells CMS

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College details aspects of proposal that it believes could prove harmful to patients and physicians alike

March 8, 2019 (ACP) –Newly proposed regulations that would govern the health insurance marketplace next year have sparked concern from the American College of Physicians, which is urging federal officials to reconsider several proposed changes that it sees as harmful.

“There are policies that would probably benefit patients, while others could reduce enrollment in the marketplaces,” explained Ryan Crowley, senior associate for health policy at ACP. “Overall, the proposed regulations continue the Trump administration's efforts to cede its oversight and regulatory duties to the states.”

Each year, the Centers for Medicare and Medicaid Services releases proposed regulations for the following year. “This ‘rule’ guides policy for the health-insurance marketplaces,” Crowley said. “They have a pretty wide scope. Among many other things, they can affect insurance regulations, risk adjustment calculations, insurance benefit rules and provider network requirements.”

In a letter to CMS sent Feb. 12, ACP cited reports that the number of Americans who have health insurance has dropped.

“We believe it is incumbent on CMS to take action to reverse this decline by stabilizing the health insurance marketplaces; providing dedicated funding for outreach, marketing, and education during open enrollment periods; and blocking the sale of extended short-term, limited duration, and association health plans that are not required to abide by the law's regulations,” wrote Dr. Ana María López, ACP's president.

The letter went on to provide extensive input on CMS's proposed policies.

On the positive front, ACP is pleased that a proposed regulation would create a special enrollment period for certain people who become eligible for subsidized marketplace insurance because of a drop in income. “If this is finalized, it would allow those who are in an off-marketplace plan to get subsidized coverage outside of the open-enrollment period,” Crowley said.

“It's a common-sense idea that could prevent people from becoming uninsured,” he said.

In addition, ACP is cautiously optimistic about a proposal to lower prescription drug costs by allowing insurers to modify formularies to include generics as they become available.

“This could be a positive thing as long as enrollees who need brand-name drugs can still access them,” Crowley said.

ACP is sounding the alarm, however, over several other aspects of the proposed regulations, including:

  • Navigator program cutbacks. “The rule proposes to scale back the Navigator program, which provides necessary insurance enrollment, education and other assistance to the public,” Crowley said. “This move is in line with the administration's efforts to cut funding for the Navigator program, which we strongly oppose.”
  • Medication-assisted treatment. “The policies attempt to warn insurers about discriminating against patients with opioid use disorder by not covering drugs for the purpose of medication-assisted treatment (MAT),” Crowley said. “It's good to see that the agency is calling out insurers for not providing better coverage for MAT, but we want to see stronger language that requires insurers to cover all approved MAT drugs without excessive prior-authorization requirements and other barriers.”
  • Narrow provider networks. “The rule does nothing to tamp down on narrow provider network plans,” Crowley said. “These plans may be cheap, but we're concerned that they don't offer people adequate access to physicians and may drive up premiums in plans with broader provider networks.”
  • Premium adjustments. ACP is concerned about plans to adjust the “premium adjustment percentage,” which is used to calculate such things as the limits on out-of-pocket spending in marketplace plans. “The proposed changes would increase premiums and lower premium tax credit amounts,” Crowley said. “As a result, CMS estimates that marketplace enrollment could drop by 100,000 each year starting in 2020. CMS expects most would become uninsured. Obviously, that's disastrous for patients and for physicians, who may see more uncompensated care costs.”

Because the comment period for the new rule has closed, CMS is in the process of determining its final policy. “Once finalized,” Crowley said, “insurers will have a short time to review and adapt to the rule before they have to start submitting the necessary application materials to the agency for approval in time for the next open-enrollment season.”

More Information

ACP's letter to CMS on the proposed rule is available on the College's website.

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