1. How Will the Trump Administration’s Upcoming Rules Change the ACA Marketplaces in 2019, and What Will the Changes Mean for Consumers Who Rely on the Market for Insurance?
Commonwealth Fund Briefing

2. Introduction Sara Collins, Ph.D.
Vice President, Health Care Coverage and Access
The Commonwealth Fund
Commonwealth Fund Briefing

3. What to Look for in the Final 2019 Notice of Benefit and Payment Parameters
Matthew Fiedler
Fellow, USC-Brookings Schaeffer Initiative on Health Policy, Economic Studies, Brookings Institution
Commonwealth Fund Teleconference
April 6, 2018
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4. Essential Health Benefits (EHB): Background
ACA requires individual and small group plans to cover ten categories of services known as “essential health benefits”
Current regulations define which services are included in each category by reference to a “benchmark” plan
Each state selects its benchmark from an HHS-specified menu of high-enrollment employer plans
Insurers must cover at least as much as the benchmark plan in each of the ten EHB categories
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5. Essential Health Benefits: “Benchmark” Proposal
States can define their own benchmarks starting in 2019 (or, alternatively, adopt all or part of another state’s benchmark)
State-defined benchmarks must:
Have an “appropriate balance” across the ten categories
“Provide benefits for diverse segments of the population”
Be “equal in scope to a typical employer plan,” but:
Typical employer plan is any plan with > 5,000 enrollees
Guidance portrays requirement as a ceiling not a floor
Bottom line: Standards are relatively vague or weak, so proposal would give states broad latitude to define EHB
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6. Implications of EHB Benchmark Proposal
Likely Effects on the Breadth of Individual Market Coverage
In states narrowing EHB, insurers drop coverage for services used by high-cost enrollees that are no longer EHB
Implications:
Premiums lower, but enrollees no longer protected against the cost of the dropped services
Subsidized enrollees get less coverage with no premium savings since tax credit fall when premiums fall
Likely Effects on Catastrophic Protections in All Private Plans
ACA ban on annual/lifetime limits and requirement to cap out-of-pocket costs only apply to services included in EHB
Large firms can choose any state’s EHB definition for these purposes, so one state’s change can have nationwide effect
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7. Essential Health Benefits: Benefit Substitution
Description of Proposed Rule
Insurers permitted to make “actuarially equivalent” benefit substitutions across EHB categories
After substitution, plan must:
Remain “substantially equal” to the benchmark
Not be “unduly weighted” toward one EHB category
Provide “benefits for diverse segments of the population”
Likely Effects if Finalized as Proposed
Insurers drop services used by high-cost enrollees, add services used by low-cost enrollees
Net effect is to shift costs toward sicker enrollees
Scope of effects depends crucially on how “substantially equal” requirement is enforced in practice
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8. Risk Adjustment: “Statewide Average Premium”
Description of Proposed Rule
States allowed to cut the “statewide average premium” in the risk adjustment formula by up to 50 percent
Effectively allows states to implement an across-the-board cut to all payments into and out of risk adjustment
Proposal limited to small group market, but HHS sought comment on expanding it to the individual market
Likely Effects if Finalized as Proposed
Insurers with sicker enrollees receive less, while insurers with healthier enrollees pay less
Insurers respond by dropping or charging more for plan features that appeal to sicker enrollees
If limited to small group market, effects likely modest; potentially large if extended to the individual market
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9. Simple Choice and Meaningful Difference
Description of Proposed Rule
Eliminates policy of giving standardized “simple choice” plan designs preferential display on HC.gov
Eliminates “meaningful difference” requirements that limit how similar an insurer’s various offerings can be
Likely Effects if Finalized as Proposed
Greater plan variety, although debatable how valuable plan variety is in this context
Comparison shopping more difficult due to greater number of plans and reduced comparability across insurers
Could make it harder to enroll and weaken price competition
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10. Commonwealth Fund Teleconference
What to Expect in the Trump Administration’s 2019 Affordable Care Act Benefit & Payment Rule
April 6, 2018
Sabrina Corlette, J.D.
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11. 2019 Payment Rule: Key Provisions
Rate Review & Medical Loss Ratio
New “unreasonable” premium increase threshold %
Rate filing, publication flexibility for states
Relaxing medical loss ratio (MLR) standards
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12. 2019 Payment Rule: Key Provisions
Navigator Program
Reduces required number of Navigator groups in each state to one
Eliminates requirement to fund community-based non-profit
Eliminates requirement to have physical presence in state
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13. 2019 Payment Rule: Key Provisions
Direct Enrollment
Obama-era initiative to allow enrollment through web-brokers or insurers’ websites
Allows consumers to bypass healthcare.gov
Proposal would make it easier for brokers, insurers to participate
Self-policing of privacy, security standards
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14. 2019 Payment Rule: What to Expect
Unlikely to change much in final rule:
Elimination of Simple Choice plans, meaningful difference standard
Provisions giving states more flexibility
Risk adjustment
Rate review deadlines, MLR adjustments
Deference to state reviews of plans
Eligibility, enrollment changes
Lack of direct notice if losing subsidy eligibility
Increased documentation of income
Navigator program
Special enrollment period changes
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15. 2019 Payment Rule: What to Expect
EHB
Effective date could be delayed
New benchmark selection options
Possible constraints on adding benefits
“Typical” employer plan
Possible tightening of criteria
A new federal standard?
Direct enrollment?
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16. Thank you!
Sabrina Corlette, J.D. Research Professor Georgetown University Center on Health Insurance
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