CMS seeks to tighten ACA subsidy rules
The changes include new special enrollment periods and criteria for automatic re-enrollment in exchange plans.
In its quest to keep ineligible people from receiving subsidies to purchase health care insurance under the Affordable Care Act, the Centers for Medicare and Medicaid is proposing to change the rules on standards that govern ACA-compliant plans.
According to Modern Healthcare, CMS is looking for feedback on whether it should terminate automatic reenrollment for low-income exchange enrollees who receive $0 premium plans with tax credits. The agency is asking whether it should require those enrollees to actively update their application during open enrollment in order to avoid having their advanced premium tax credits for the next year terminated or cut.
Related: Pharmacy benefit managers crack down on copay assistance programs
Exchanges, meanwhile, would no longer have to redetermine whether an enrollee is eligible for financial subsidies when it processes a voluntary termination of exchange coverage for someone who is dually enrolled in other qualifying coverage; at present, that is a requirement for the exchanges. They would also no longer have to redetermine eligibility for subsidies when an enrollee is identified through periodic data matching as deceased, which CMS said would lower the risk of incorrect subsidy payments.
According to CMS, “We remain concerned that automatic reenrollment may lead to incorrect expenditures of (advanced premium tax credit), some of which cannot be recovered through the reconciliation process due to statutory caps. We believe that there may be particular risk associated with enrollees who are automatically reenrolled with APTC that cover the entire plan premium, since such enrollees do not need to make payments to continue coverage.”
The changes are included in the proposed HHS Notice of Benefit and Payment Parameters for 2021, with comments due on March 2.
Another proposed change would target a regulation finalized for the 2020 plan year that let health insurers implement copay accumulator programs so that coupons from drug manufacturers could not be used toward a patient’s annual limit on out-of-pocket costs when a generic drug is available. Instead, for 2021, the proposal would extend the policy to let insurers exclude drug manufacturer coupons from applying to the annual limit on cost-sharing even when there is no generic drug available.
“Not only will it increase patients’ costs, but it will translate in insurance companies collecting even more money off prescription drugs,” Carl Schmid, the former deputy executive director of the AIDS Institute who is now with the newly formed nonprofit organization HIV + Hepatitis Policy Institute, is quoted saying of the proposal, which he said would make it more difficult for patients to afford and continue taking their medications. He added, “We urge HHS not to finalize such an anti-patient proposal.”
Other changes proposed include the addition of a few new special enrollment periods; technical changes to the way insurers’ medical loss ratios are calculated; a move toward value-based insurance plan designs to push patients to look for higher-value care at lower costs; technical updates to the risk adjustment program; and updates to the maximum annual limit on how much patients can pay out-of-pocket for their medical care. CMS proposes increasing that limit to $8,550 for self-only coverage and $17,100 for family coverage, which amounts to a 4.9 percent increase above 2020 limits.
Read more: