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Stephanie Pellitt

Policy and Advocacy Associate

CMS Finalizes Rule to Stabilize Insurance Market, Relaxes Network Adequacy

April 20, 2017 | ACA | Comments
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Last Thursday, the Centers for Medicare and Medicaid Services (CMS) issued its highly anticipated final rule on stability in the individual and small group insurance markets, including the exchanges. The agency said the rule is designed to provide “short-term relief for patients and issuers now” but cautioned that it would not represent a “long-term cure.” The final rule keeps most of the changes the Department of Health and Human Services proposed in February – including more flexibility in the way insurers can calculate the value of their coverage and deferring network adequacy requirements to the states.

The new rule includes several additional changes requested by insurers:

  • Reducing the duration of the sign-up period for 2018 by half, from Nov. 1 to Dec. 15;
  • Requiring people who sign up for coverage in special enrollment periods to prove they qualify ­– for example, if they moved and need new a new plan. This change is intended to cut down the ability of people to sign up for coverage after they get sick;
  • Allowing insurers to require that people pay past-due premiums before enrolling in a new plan with the same insurer the following year; and
  • Allowing insurers the flexibility to offer health plans with fewer options.

In addition to tightening insurance enrollment standards, the new rule gives states greater authority to review provider networks. Beginning with the 2018 plan year, HHS will forgo its oversight in states that have the authority to review network adequacy, and instead rely on state regulators to ensure network adequacy. In states where the state lacks authority or means to ensure network adequacy, HHS will look to an insurer’s accreditation from an HHS-recognized accreditation body.

The final rule also includes a key deadline for insurers – they will have until June 21, 2017 to tell the government whether they will participate in the federal ACA marketplace. However, it is important to note that the final rule does not address the insurance industry’s primary concern regarding the importance of continued enforcement of the individual mandate.