Last week, (April 13, 2017), the Department of Health & Human Services (HHS) adopted new regulations, aimed at increasing the stability of the health insurance market. Finalizing its proposed rule, this final ruling takes into consideration over 4,000 comments gathered during a 20-day public commentary period.

Among the measures outlined in the guidance, the final ruling plans to improve the risk pool, promote stability in the individual market, increase incentives for consumers to maintain coverage, and decrease those for individuals that enroll after discovering they require medical treatments. It also responds to concerns about misuse and abuse of special enrollment periods (SEP) in the individual health insurance market.

Here’s a list of what you should know:

  1. The 2018 PY open enrollment period (OEP) for individual major medical coverage will run from Nov. 1, 2017 through Dec. 15, 2017.
  2. All consumers who select plans on or before December 15, 2017 would receive an enrollment effective date of January 1, 2018.
  3. Individuals will be required to enroll in coverage before the beginning of the year, unless they are eligible for special enrollment periods and it is consistent with OEP for 2016 PY and beyond. This measure is intended to improve the individual market’s risk pools.
  4. The final ruling prevents individuals who are not entitled to special enrollment periods (SEP) from enrolling in coverage after they discover medical treatments are necessary.
  5. Pre-enrollment verification will be increased for all individual market special enrollment periods for states using, from 50 to 100% of new consumers trying to enroll via a SEP.
  6. Requires all consumers who apply for “special enrollment periods,” or exceptions to the usual individual major medical open enrollment period deadline, through to provide documents showing they qualify for SEPs before they get health coverage in place.
  7. Institutes revisions to the Federal Guarantee Availability Requirement to allow issuers to apply a premium payment to an individual’s past debt owned for coverage from the same issuer, or a different issuer in the same controlled group, within the prior 12 months before applying the payment towards a new enrollment.
  8. Increases the de minimis variation in the actuarial values (AVs) utilized in incorporating metal levels of coverage for the 2018 plan year and beyond.
  9. HHS also mentioned that they are finalizing polices that will affirm the traditional role of States in overseeing their health insurance market while reducing the regulatory burden of participating in Exchanges for issuers.
  10. Insurers that offer non-grandfathered insurance coverage in the group or individual market will be required to offer coverage to, and accept every employer and individual in,the state that applies for coverage, unless exceptions apply.
  11. Binder payment requirements have been amended for consumers whose enrollment was delayed due to an eligibility verification to delay the coverage start date.
  12. A new pre-enrollment verification of eligible for Exchange coverage for applicable categories of special enrollment periods for all new consumers in all States served by healthcare, including FFEs and SBE-FPs. HHS would verify the eligibility for all new consumers who seek enrollment through the Exchange via SEP.
  13. Consumers can request a later coverage effective date than originally assigned if his or her enrollment was delayed due to an eligibility verification and the consumer would be required to pay 2 or more months of retroactive premium to effectuate coverage or avoid cancellation.
  14. To ensure a SEP for loss of minimum essential coverage is not granted in cases where an individual is terminated for non-payment of premium, we propose that FFE and SBE-FPs will permit the issuer to reject an enrollment that the issuer has a record of termination for due to non-payment of premiums by the individual (unless the individual fulfills obligations for premiums due for previous coverage).
  15. If consumers are newly enrolling in QHP coverage through the Exchange through the SEP for marriage, at least one spouse must demonstrate having had a minimum essential coverage for 1 or more days during the 60 days leading up to the date of marriage.
  16. The final ruling eliminates 5 special enrollment periods:
    1. Consumers who enrolled with APTC that is too large because of a redundant or duplicate policy;
    2. Consumers who were affected by a temporary error in the treatment of SSI for tax dependents;
    3. Lawfully present non-citizens that were affected by a temporary error in the determination of their eligibility for APTC;
    4. Lawfully present non-citizens with incomes below 100 percent FPL who experienced certain processing delays; and
    5. Consumers who were eligible for or enrolled in COBRA and not sufficiently informed about their coverage options.
  17. HHS is working to update the QHP certification calendar and the rate review submission deadlines to provide additional time for issuers to develop, and States to review, form, and file rate filings for the 2018PY
  18. The definition of de minimis has been amended to include a variation of -4/+2 percentage points, opposed to +/- 2 percentage points for all non-grandfathered individual and small group market plans (other than bronze plans that meet certain conditions) that are required to comply with AV. This is aimed at providing Issuers with greater flexibility to make adjustments to their plans within the same metal level.
    1. To maintain the bronze plan de minimis range policy finalized in the 2018 Payments Notice, the de minimis range will be expanded for bronze plans from -2/+5 percentage points to -4/+5 percentage points
  19. HHS has changed their approach of reviewing network adequacy in States that do not have the authority and means to conduct sufficient network adequacy reviews.
  20. For conducting reviews of the ECP standard and SADP certification for the 2018 PY, HHS will return to the percentage used in the 2014 PY and consider the issuer to have satisfied the standard if the issuer contracts with at least 20 percent of available ECPs in each plan’s service area to participate in the plan’s providers network.

The views and opinions expressed by the authors on this blog website and those providing comments are theirs alone, and do not reflect the opinions of Softheon, Inc. or any employee thereof.

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Yvonne Villante

Director of Marketing at Softheon
Yvonne Villante is the Director of Marketing at Softheon. Before this, Yvonne held several roles within the organization including Senior Research Manager, Corporate Research Manager, and Marketing Research Analyst. She holds a MBA in healthcare administration from Ohio University and a BS in business management from SUNY Stony Brook. During her undergraduate studies, she graduated within the top 10% of her class.
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