Showdown in Washington – Will CMS listen to the Republicans?

Despite no “Repeal and Replace” solution from the Republicans, the battle continues as CMS announces major changes for the 2018 Marketplace Health Insurance Enrollment Period. In a move that surprised many, CMS agreed to the following concessions:

  • Consumers who apply for a Special Enrollment Period (SEP) must prove they have lost coverage prior to enrolling. Currently, very little documentation and oversight by CMS exists.
  • Allow insurance carriers more leniencies when calculating Actuarial Values for every plan. Probably one of the most frustrating parts of the ACA, each year plans change deductibles and out of pocket limits due to the AV calculations. What was supposed to create uniformity in the market has created less coverage each year for consumers.

While the CMS changes are welcomed, the bigger challenge lies within the insurance carrier retreat from the market. Insurance carriers are owed some 8 billion dollars as part of the risk corridor calculations that was agreed upon in 2010 when the ACA was passed. The risk corridors were put in place to help insurance carriers manage risk in the first three years of the marketplace. In anticipation of larger claims costs due to the elimination of pre-existing condition limitations and guaranteed issue provisions, insurance carriers knew they would lose lots of money in the markets. United bailed after the second year, Humana after the third, most COOPS are now defunct, and now even the Blues have warned CMS that an exit could happen in some states for 2018. What if there were no health insurance carriers in a particular state? It may become a reality.
Risk Corridor reimbursement is at the top of the list for the insurance carriers, and the Republicans are having a difficult time swallowing another bailout in D.C. It’s really not a bailout but a commitment on a promise made in 2010.

Stay tuned as another budget battle looms over the country, and healthcare is at the core of the debate.

Burman S. Clark

Burman S. Clark, RHU, CSA is the President of Muneris Benefits and a licensed insurance broker and consultant. His independent practice and focuses on employee benefits, individual life, disability, medical, and senior products. Burman has traveled extensively and provided guidance to large employer associations with regards to the Affordable Care Act.