CMS Moves Quickly to Strengthen Exchanges

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Following the announcement by Aetna that it will cease operating on all but four Exchanges in 2017, and in response to growing speculation that the Exchanges may be in trouble, the Centers for Medicare & Medicaid Services (CMS) quickly took steps it believes will strengthen the Exchanges and address concerns expressed by consumers and insurers.

CMS released its proposed Notice of Benefit and Payment Parameters earlier this year than is normal and explained that it includes “a set of critical actions based upon our first 3 years’ experience that, if finalized, would improve how consumers and health plans interact with the Marketplace.”  Examples of these actions include:

  • Changes to the risk adjustment program.  Starting in 2017, the program would be changed to more accurately reflect the risk associated with enrollees who are only enrolled for part of the year.  In 2018, the program would begin using prescription drug utilization data and changes would be implemented to better allocate the risk of high-cost enrollees across insurers.
  • Adjustments to child age bands.  For plan years beginning in 2018, there would be one age band for children 0 – 14 years of age and then single-year age bands for those 15 – 20.  CMS explained that using single-year age bands starting at age 15 will likely cause small premium increases through age 20 but it will ease transition into the adult rating at age 21.
  • Special enrollment limitationsCMS seeks to finalize certain special enrollment periods provided in earlier guidance, including those for victims of domestic abuse or those who apply but are later determined ineligible for Medicaid coverage.  Also, in response to concerns that special enrollment periods are being misused and some individuals are waiting until they get sick to enroll in coverage, CMS seeks comments on other special enrollment periods or limitations that would ensure individuals will be able to enroll in coverage but without compromising the strengthen of the risk pools.

Shortly before the release of the proposed rules, CMS issued a request for information seeking comments on concerns raised by issuers that some health care providers may be steering Medicare and Medicaid eligible individuals into Exchange plans in order to receive higher reimbursement rates.  CMS is not only concerned these actions could negatively impact the risk pools resulting in higher costs for coverage but that it may disrupt patients’ continuity and coordination of care.