Massachusetts Health Connector Issues Public Comment on Centers for Medicare & Medicaid Services Proposed Rule
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The Massachusetts Health Connector ("Health Connector"), a state-based Marketplace (SBM) authorized under the Patient Protection and Affordable Care Act of 2010 ("ACA"), appreciates the opportunity provided by the
Founded in 2006 as part of bipartisan state health reform, the Massachusetts Health Connector is the longest-running
While CMS offered guidance on a number of important areas for Marketplaces to consider, our comments focus on areas where the proposed rule would have a direct impact on the policy-related or operational aspects of the Health Connector's ongoing work. We respectfully offer the following comments relating to the proposed rule.
The Health Connector does not support the expanded use of direct enrollment entities because doing so would undermine the purchasing power and trusted brand of Exchanges nationwide. (45 CFR 155.20, 106, 106, 205, 206, 221)
The Health Connector has significant concerns with CMS's proposal to allow states to waive their federal or state-based exchange in favor of allowing private entities to directly enroll individuals in qualified health plans (QHPs). In addition, the Health Connector does not support CMS's proposals to allow web-brokers to limit the display of information about a qualified health plan or delay website language translation requirements for enhanced direct enrollment entities (EDE) websites. CMS's direct enrollment proposals run counter to the intent and purpose of the ACA by reducing consumer protections, interfering with transparency and competition, and providing no clear value over existing Exchange pathways.
Consumer Protections
Without a clear, consistent, and trustworthy pathway to enrollment, consumers are likely to struggle in finding the health coverage benefits they need and to which they are entitled. Direct enrollment (DE) does not support the ACA's "no wrong door" policy which enables consumers to use a single, streamlined application to determine eligibility and enroll in Medicaid, CHIP, or Exchange coverage. Consumers interacting with a DE entity may not be made aware of eligibility for certain programs and instead be directed to options that are less affordable and less generous than what they would have been determined eligible for through the streamlined application. Consumers left unaware of their eligibility for subsidized coverage may choose to forgo coverage altogether. In addition, delaying website translation requirements would severely burden limited English proficient (LEP) individuals and impede their access to health coverage and health care services.
Consumers are already confused by the actions of private companies with misleading and deceptive marketing practices. The expansion of direct enrollment entities exacerbates this problem and creates additional challenges for consumers trying to find their way to legitimate, comprehensive coverage. In recent years, the Health Connector has been made aware of a variety of entities deceptively marketing scam plans or products not covering core comprehensive medical benefits to
The
In addition, the
The Massachusetts DOI warning noted that the type of coverage Aliera was offering did not have the same consumer protections as traditional insurance plans and may not have guaranteed payments for medical services or expenses. In response to both instances, the Health Connector took steps to assist harmed residents by opening up Special Enrollment Periods for affected individuals.
Similar deceptive marketing practices targeting more than 15,000 individuals seeking traditional health coverage, including Exchange coverage, are also detailed in a recent complaint filed by
Competition
By design, exchanges allow consumers to make "apples-to-apples" comparisons of available qualified health plans by displaying all options available along with important comparative information such as premiums, cost-sharing information, and provider directories. This impartial and complete display of certified plans promotes competition and informs consumers that all coverage options through an Exchange are comprehensive and trustworthy.
Direct enrollment entities complicate the shopping process for consumers and risk decreasing competition due to the differences in plan and information display requirements. CMS's proposal to provide web-brokers with additional flexibility in how Qualified Health Plan (QHP) information is displayed would further distort DE shopping behavior, stifle competition, and reduce affordability for consumers.
Value
CMS's proposed direct enrollment option relies heavily on direct enrollment entities without clear evidence that these pathways provide more value than ACA exchanges or have increased overall enrollment. For example, while consumers have had the option to pursue direct enrollment and enhanced direct enrollment pathways for several years, these entities only account for one third of FFE enrollment./6
Since direct enrollment entities can already exist alongside Exchanges, a push towards a decentralized and private alternative appears unsupported by evidence of increased efficacy in pursuit of the consumer focused or market-oriented goals of the ACA.
Establishing a centralized health insurance exchange helped to propel the Commonwealth from seventh place in the percentage of insured residents to first place, a ranking
The Health Connector supports maximum special enrollment period (SEP) flexibility for individuals experiencing life events, such as losing eligibility for APTC, and supports new triggering event for individuals whose employers stop paying for COBRA coverage. (45 CFR 155.420)
Special enrollment periods allow individuals to access coverage at crucial periods of change in their lives.
The Health Connector applauds the proposal to allow a special enrollment period for individuals whose employers stop contributing to COBRA coverage, which can diminish the utility of the COBRA coverage and provide a natural inflection point for exploring and enrolling in more affordable coverage options through an Exchange. Changes in employment that lead to the need for COBRA coverage are often deeply disruptive to a household. Having flexibility to take employer-subsidized COBRA for a period of time before switching to Exchange coverage would ease what is likely a difficult time. The Health Connector would also support a special enrollment period triggered by a reduction in COBRA subsidy, as even a relatively small increase in monthly costs may be untenable for a family with reduced income, and recommends that CCIIO consider this addition of criteria, as well, upon finalization of the proposed rule.
The Health Connector also supports the proposed change to exempt individuals losing advance premium tax credits (APTCs) from limitations placed on consumers' ability to switch metallic tiers during a special enrollment period. It seems likely that individual choosing to switch plans after losing subsidies would do so out of affordability concerns rather than attempt to better fit a plan's cost sharing to their utilization.
The Health Connector does not recommend that CMS require special enrollment period (SEP) eligibility verification for 75% of new enrollees. (45 CFR 155.420)
The Health Connector recommends continued state flexibility regarding verification of eligibility for special enrollment periods to allow for a process closely tailored to each state's market's needs. Considering that the Health Connector already has a robust SEP verification process and works closely in collaboration with its carriers, CMS's proposal to codify SEP verification requirements creates extra burden and cost on administrative processes without any added benefit.
CMS estimates that state-based Exchanges would incur an additional
The Health Connector asks that CMS continue to allow and support states in determining the best way to finance their Exchange operations. (45 CFR 156.50)
The Health Connector has used an administrative user fee to finance Exchange operations since its inception. In part, the Health Connector uses this funding to provide enrollment and billing infrastructure to its carriers, which has reduced barriers for new entrants to the market and contributed to a robust selection of nine medical and four dental carriers from which
The Health Connector is concerned that CMS's proposed reduction of the FFM user fee will jeopardize already-reduced investments in enrollment and outreach support for the FFM and leave the FFM generally under-resourced relative to the needs of the public it serves. Enhanced outreach and marketing would be particularly valuable at this time, as these activities are a critical component of expanding coverage, as well as ensuring market stability and affordability. Over the last four years, insurance coverage rates have declined substantially nationwide, indicating increased need for consumer supports to find those uninsured individuals a pathway to coverage. Future efforts to improve marketplace functionality, consumer assistance and marketing rely on the user fee and are essential to ensuring a strong FFM, which of course directly benefits consumers in states that rely on the FFM, but also assists state-based exchanges like the Health Connector by amplifying and reinforcing our local work to promote awareness of and enrollment in health coverage.
The Health Connector recommends that CMS discontinue inclusion of individual market premiums in calculating the premium adjustment percentage. (45 CFR 156.130)
In keeping with
Previously, individual market premiums were not included in the premium adjustment percentage formula to allow time for volatility in the individual market during ACA implementation to settle. In many ways, ACA markets are beginning to mature and stabilize, particularly in states like
The indexing methodology places the burden of rising health care costs and sluggish wage growth squarely on households that have no meaningful way of changing the trajectories of those measures, which CMS acknowledges will result in added cost burdens to consumers. In addition, the already high consumer cost burden is exacerbated by the economic fallout of the COVID-19 pandemic. Rising costs paired with flagging wages should result in higher subsidies and lower cost sharing, not the other way around. As this federal administration has noted, health coverage policy should support the hardworking Americans who struggle to pay premiums and absorb out of pocket costs, not increase their burden. We urge CMS to uphold this principle by reverting back to the premium adjustment methodology that does not include individual market premiums when indexing advance premium tax credits and cost sharing limits.
The Health Connector recommends that CMS not codify the 2018
The Health Connector does not support codifying the guidance published by the Secretary of
The 2018 guidance promotes state proposals that may expand less comprehensive coverage, expose consumers to more cost-sharing and out-of-pocket costs, and burden vulnerable populations.
The 2018 guidance fails to ensure that comprehensive and affordable coverage would be available to a comparable number of residents under a proposed waiver. Under the 2018 guidance, states do not have to guarantee that coverage within their waivers is considered "minimum essential coverage"; instead, coverage may include "health insurance coverage" as defined under 45 CFR 144.103. Health insurance coverage under this broad definition includes limited coverage options, such as short-term limited duration insurance, that lack vital consumer protections central to the ACA. The intent of the ACA Section 1332 waiver option was to allow state innovation while still upholding robust ACA standards, not to undermine the benefits the ACA brings to consumers.
The COVID-19 pandemic has disproportionately impacted vulnerable populations and magnified existing health disparities, making it more important than ever to ensure equitable access to comprehensive health coverage. The 2015 Section 1332 waiver guidance appropriately ensured consideration of impacts across different populations with particular attention to impacts on vulnerable residents. The 2018 guidance, by only focusing on the aggregate impacts of a state's 1332 waiver, allows states to pursue proposals that may disproportionately harm vulnerable populations' access to comprehensive and affordable coverage.
The Health Connector asks that CMS inform state Exchanges of enforcement actions taken related to their QHP issuers. (45 CFR
In response to CMS's proposed increase in oversight, audit, and enforcement authority with QHP issuers, the Health Connector respectfully requests that CMS ensure Exchanges are notified of any action taken related to its issuers. As CMS notes, primary enforcement authority over QHP insurers and ensuring compliance with APTC, CSR, and user fee standards lies with state Exchanges; therefore, ensuring the Health Connector is informed of any actions taken against its QHP issuers will prevent duplication of efforts. In addition, it is especially important that Exchanges receive timely notice of action CMS plans to take against issuers if that action could potentially impact Exchange operations or member experience.
The Health Connector appreciates the proposed rule's continued accounting for
The Health Connector thanks CMS for continuing to include an adjustment to the federal risk adjustment methodology that accounts for different market dynamics resulting from the ConnectorCare program, which provides additional state-funded premium and cost sharing subsidies to individuals eligible for advance premium tax credits. The ConnectorCare program is integral to the coverage landscape in
We thank you for consideration of our comments and look forward to working with CMS on continued implementation of the ACA.
Sincerely,
Executive Director
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Footnotes:
1/ See www.mass.gov/news/massachusetts-named-healthiest-state-in-the-nation.
2/
3/ Analysis of CMS Public Use Files, at www.cms.gov/CCIIO/Resources/Data-Resources/marketplace-puf.html.
4/
5/
6/ Health Affairs, at https://www.healthaffairs.org/do/10.1377/hblog20201127.118789/full/
7/ Report to the Massachusetts Legislature Implementation of the Health Care Reform Law, Chapter 58 2006-2008
8/ KFF, at https://www.kff.org/wp-content/uploads/2013/01/8311.pdf
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The proposed rule can be viewed at: https://www.regulations.gov/document?D=CMS-2020-0151-0005
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