The Centers for Medicare & Medicaid Services (CMS) published its annual proposed changes to benefit and payment parameters for federal health care marketplaces, state-based marketplaces on the federal platform, and state-based marketplaces. Proposed changes aim to increase transparency and make it easier to enroll in and maintain health care coverage.
Currently, marketplace enrollees may become ineligible for the advance premium tax credit (APTC) if they fail to file and reconcile (FTR) their federal income tax return for two consecutive years. CMS currently requires marketplaces to notify enrollees the first year they FTR their income taxes. The agency proposes to require that marketplaces also notify enrollees when they FTR for the second consecutive year and face losing their APTC.
Fixed Premium Threshold
Further, CMS proposes more flexibility for insurers to enable consumers to maintain coverage even if they have not paid their full premium. Currently, issuers can adopt a percentage-based premium threshold that avoids triggering a grace period for non-payment, allowing enrollees to maintain coverage even when they have not paid their premium in full. CMS proposes to allow a fixed premium payment threshold of $5, which better accounts for consumers with low premiums, such as $1. Issuers could choose between the percentage or fixed threshold depending on their consumers’ needs.
Marketplace Standards Violations
CMS plans to expand its authority as needed to suspend marketplace agents and brokers from using the marketplace itself. The agency also proposes to apply compliance reviews and enforcement actions to lead agents at insurance agencies to hold them responsible for marketplace standards violations.
Other proposed changes focus on basic health plan payment methodology, standardized plan options, and public reporting.
Finally, CMS seeks comments on how the agency can use its authority related to navigators and other assisters to link patients to financial assistance programs within hospitals to reduce medical debt.
Comments are due Nov. 12.
Contact Director of Policy Rob Nelb, MPH, at rnelb@essentialhospitals.org or 202.585.0127 with questions.