AHA, community organizations react to CMS’ ‘Benefit and Payment Parameter’ proposed rule

The American Hospital Association (AHA) and I Am Essential, an organization representing 138 patient and community organizations, have expressed their concerns that many of CMS’ proposed changes to the rules for the health insurance marketplace included in its Notice of Benefit and Payment Parameters for 2019 (proposed rule, 82 FR 51052, November 2, 2017) will diminish patient care and increase beneficiary out of pocket costs. In addition, AHA noted that several proposals would drive up the costs of coverage and reduce patient access to care, while other proposals could result in health plans that cover fewer benefits. I Am Essential focused some of its comments on patient protections included in Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) and the need to enforce those current regulations and guidelines to ensure beneficiaries’ access to quality health care.

CMS’ proposals.

CMS’ proposed rule would amend previously implemented programs and requirements of the ACA to focus on enhancing the role of states in these programs, providing states with additional flexibilities, reducing unnecessary regulatory burden on stakeholders, empowering consumers, and improving the affordability of health insurance. Specifically, the proposed rule would expand the state role in the administration of the ACA in essential health benefits (EHB) (section 1302(b)(2)), exchange innovation, qualified health plan certification process (QHPs) (section 1301), Small Business Health Options Program (SHOP) (section 1321), and medical loss ratio (MLR) (section 1331(b)(3)). In addition, CMS proposed modifications to risk adjustment parameters, user fee rates (section 1311(d)(5)(A)), the premium adjustment percentage, cost-sharing, rate reviews, and Navigators.

Major concerns regarding EHBs.

AHA as well as the community organizations have urged CMS to abandon its changes to EHBs. In AHA’s opinion, reducing the benefit package is not the most effective way to reduce the cost of coverage, it would only reduce the cost of premiums and patients would face higher out of pocket costs. In addition, expanding the parameters for states to identify EHBs in relation to identifying a typical employer plan, does ensure that states may not identify employer sponsored plans that do not provide adequate or comprehensive coverage.

Essential Community Providers (ECPs).

AHA supported provisions of the proposed rule that reduces administrative burdens without negative consequences for patients but opposes a policy implemented last year that requires QHPs to only contract with 20 percent of ECPs as opposed to the 30 percent threshold implemented in the past. AHA is concerned that the access needs for vulnerable communities may not be met.


AHA supports CMS proposal to reduce duplicative reporting requirements by expanding states’ oversight role of QHPs; however, AHA advises CMS to proactively monitor state performance in this area. AHA expressed concern that some states do not have the expertise or staff capacity to fully monitor health plan performance. AHA also supports the elimination of the “meaningful difference” requirement to reduce consumer confusion by prohibiting insurers from offering multiple plans that are essentially the same. The community organizations, however, oppose the elimination of the meaningful difference standard as well as the standardized plan option.

MLR standard.

Under the proposed rule, CMS would allow states to adjust the 80 percent MLR standard for the individual market if the state can demonstrate that a lower MLR standard would stabilize the individual market. AHA does not support CMS’ proposal to diminish the MLR standard. According to AHA, the current MLR standard is not the primary reasons for insurers to withdraw from or choose not to participate in the marketplaces. AHA also would like CMS to postpone any action related to MLR calculations involving employment taxes to have time to collect and access how deducting federal and employment taxes would affect the MLR standard.

Opinions on other proposals.

AHA opposes the CMS proposal to raise the threshold for premium increases from 10 percent to 15 percent and urges CMS to keep the current 10 percent threshold as an important accountability measure for consumers and the U.S. Treasury. AHA also is opposed to CMS changes to the Navigation program and encourages CMS to fully fund the Navigator program. AHA sees Navigators as an important source of information in terms of consumer outreach and education and marketing of exchanges.

SOURCE: American Hospital Association and I Am Essential Letters to HHS, November 27, 2017.
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