CMS has released proposed HHS Notice of Benefit and Payment Parameters for 2018.
"The focus of this rule is clearly stabilizing the market," Elizabeth Carpenter, senior vice president at Washington, D.C.-based healthcare consulting firm Avalere, told Becker's Hospital Review. "It focuses less on benefit issues that are directly impacting consumers."
Here are 15 proposals from the notice, which proposes standards for insurers and each health insurance marketplace for the 2018 benefit year.
1. Incorporate partial year adjustment factors in the adult 2017 and 2018 benefit year risk adjustment models. CMS said the proposal addresses feedback that the current model underpredicts claims costs for enrollees who are enrolled for a partial year.
2. Use prescription drug utilization data to better account for health risk linked to covering unhealthy individuals. CMS said this will enhance the predictability of risk adjustment models in 2018.
3. Change the treatment of high-cost enrollees. CMS proposes creating a pool of high-cost enrollees in which an adjustment to insurers' transfers would finance 60 percent of costs when individual costs top $2 million.
4. Publish final 2018 benefit year coefficients earlier, before 2018 benefit year risk adjustments are calculated.
5. Use data from external data gathering environment servers to recalibrate 2019 risk adjustment models. External data gathering environment (EDGE) servers are systems insurers use to submit data for risk adjustment and reinsurance programs.
6. Amend the risk adjustment data validation process to include the review of proposals regarding prescription drug data, random insurer sampling below a certain size and the establishment of discrepancy and administrative appeals processes.
7. Maintain a federally-facilitated marketplace user fee of 3.5 percent of premium for 2018. The fee remains the same as it was from 2014 to 2017. CMS also proposed a 3 percent user fee for insurers participating in a state-based marketplace on the federal platform in 2018.
8. Increase the premium adjustment percentage to approximately 16.17 percent, up 2.6 percent from 2017. The premium adjustment percentage sets the rate of increases for the maximum annual limit on cost sharing, the required contribution percentage for eligibility for exemptions and the affordability percentage for calculation of assessable payment amounts.
9. Reassess CMS' 5-year ban on market reentry when insurers inadvertently trigger a market withdrawal. CMS proposed a non-grandfathered product could be considered the same product when offered by a different insurer within an insurer's controlled group if the product meets certain standards. In addition, insurers can replace all existing products with new products without leaving a market if the insurers match new products with current products.
10. Propose a 2018 maximum annual limitation on cost sharing of $7,350 for individual coverage and $14,700 for family coverage.
11. Maintain limitation on dental annual cost sharing at $350 for one child and $700 for one or more children.
12. Update standardized options. CMS proposed increasing the number of standardized options, with the intent that at least one standardized option in each coverage level will comply with state requirements. Also proposed was a standardized health savings account-eligible bronze high-deductible health plan option.
13. Code several special enrollment periods already available to consumers to ensure rules are clear and limit abuse.
14. Change the child age rating to one age bracket for individuals ages 0 through 14 and then single-year age brackets for individuals ages 15 through 20.
15. Extend medical loss ratio provision to allow insurers to defer reporting newly issued polices with a full 12 months of experience. In addition, the notice proposed a limit of total rebate liability payable in certain situations.
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