Proposed Regulations CMS-9930-P
Proposed Regulations CMS-9930-P

Proposed rule  CMS-9930-P sets forth payment parameters and provisions related to the risk adjustment and risk adjustment data validation programs; cost-sharing parameters and cost sharing reductions; and user fees for Federally-facilitated Exchanges and State-based Exchanges on the Federal platform.

It proposes changes that would enhance the role of States as related to essential health benefits (EHB) and qualified health plan (QHP) certification; and would provide States with additional flexibility in the operation and establishment of Exchanges, including the Small Business Health Options Program (SHOP) Exchanges.

It includes proposed changes to standards related to Exchanges; the required functions of the SHOPs; actuarial value for standalone dental plans; the rate review program; the medical loss ratio program; eligibility and enrollment; exemptions; and other related topics.

CMS proposes rule to allow states more latitude in defining essential benefits. Modern Health Care 10.27.2017  *  Considering how many extra benefits CA has, I doubt CA will lower any benefits.

These are some of the biggest changes

  1. States could replace their benchmark plan defining minimum essential health benefits with all or part of another state’s benchmark plan.
  2. States could establish a new benchmark plan for essential health benefits as long as it’s equal to the scope of benefits provided under a typical employer plan. Typical is defined as any employer plan in the small-or large-group market with at least 5,000 employees.
  3. HHS would defer to state review of the adequacy of health plan provider networks and expand the role of states in certifying qualified health plans offered on the federal insurance exchange.
  4. States could lower the ACA requirement that individual-market health plans spend at least 80% of premium revenue on medical costs, if they demonstrate that a lower medical loss ratio would help stabilize the market.
  5. Health plans proposing to raise premiums would not be subject to regulatory review for “unreasonable” increases unless the proposed hike is 15% or more, compared to a 10% threshold now.
  6. Each ACA exchange would no longer be required to have at least two enrollment navigator organizations. And there no longer would have to be at least one consumer-focused not-for-profit navigator group with a physical presence in the local area.
  7. The federal exchange no longer would maintain a website and payment platform for the Small Business Health Options Marketplace, or SHOP. State-based SHOP marketplaces could continue if they choose to do so.
  8. Standardized health plan options, [Metal Levels] created by the Obama administration to simplify consumer choice on the exchanges, would be eliminated. The CMS said this would encourage innovation.
  9. Consumers who relocate or get married would have to demonstrate prior coverage during the previous 60 days to qualify for special enrollment outside the open enrollment period.
  10. Hardship exemptions waiving the requirement that people buy coverage would be expanded by basing the affordability test on the cost of a silver plan if no bronze plan is available in that market. Modern Health 10.30.2017 *


45 CFR Parts 147, 153, 154, 155, 156, 157, and 158
RIN 0938-AT12
Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2019

Resources & Links

Executive Orders – CMS – CFR Rules to help or hobble ACA – Obamacare





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