Introduction
The Centers for Medicare & Medicaid Services (CMS) released new proposed rules on October 4, 2024, targeting the Affordable Care Act (ACA) marketplace. The proposed changes, which will take effect in 2026, focus on addressing fraud, improving agent accountability, and enhancing coverage protections. CMS aims to strengthen the exchange’s operational security while providing flexibility to consumers and insurers.
Overview of the Proposed Rules
The CMS proposal aims to ensure greater transparency, reduce fraud, and streamline risk management in the ACA marketplace. These measures also address recent complaints from consumers regarding unauthorized changes to health plans and coverage enrollment without consent.
Key Changes to Agent Accountability
CMS proposes holding insurance agency lead agents responsible for violations of marketplace standards. In a significant shift, CMS will suspend agents or brokers from the exchange if they pose a security risk. This change is designed to enhance the overall trustworthiness of the marketplace by deterring agents from unethical practices.
Enhanced Consumer Protection Against Unauthorized Coverage Changes
Unauthorized changes to coverage have become a growing issue. CMS reported 74,000 complaints regarding unauthorized plan modifications and 130,000 cases of individuals being enrolled in coverage without their knowledge in the first half of 2024.
In response, CMS has already suspended over 200 agents since June on suspicion of fraud. The new rules will ensure stricter monitoring and enforcement to reduce these incidents.
New Consent Documentation Requirements
The proposed rules also introduce a model consent form for agents and brokers to obtain and document customer consent more effectively. This step aims to reduce instances of enrollees unknowingly being enrolled or moved to different plans.
Premium Payment Flexibility for Enrollees
To prevent coverage disruption due to small unpaid premiums, CMS suggests new premium payment rules. Insurers would be allowed to set fixed-dollar or percentage-based thresholds, capped at $5, enabling enrollees to maintain coverage even if they miss a small portion of their monthly premium.
Risk Adjustment Program Updates
The CMS proposal includes significant updates to the risk adjustment program, which ensures fair distribution of costs across insurers in the ACA marketplace. The updated models will incorporate data from 2020 to 2022, reflecting recent trends in healthcare usage and costs.
Addressing Hepatitis C and HIV Drug Costs
In line with the proposed updates, CMS plans to phase out special adjustments for Hepatitis C treatments and introduce new adjustments for pre-exposure prophylaxis (PrEP) drugs to treat HIV. These changes will help align drug cost adjustments with current medical needs.
Preventing Insurer Insolvencies in the Marketplace
Insurer insolvency has emerged as a concern in recent years, leaving enrollees stranded without coverage. CMS is seeking public input on potential strategies to mitigate this risk and ensure financial stability in the ACA marketplace.
Public Comment Period and Timeline
CMS is accepting public comments on the proposed rules until November 12, 2024. This feedback will play a crucial role in shaping the final version of the regulations.
FAQs
Q1: What is the primary focus of CMS’ proposed ACA rules for 2026?
A. The primary focus is to reduce fraud, enhance consumer protection, and ensure stability in the ACA marketplace.
Q2: What consumer protection measures are being introduced?
A. CMS will implement stricter monitoring to prevent unauthorized plan changes and introduce a consent form to document enrollee approvals.
Q3: How will the new premium payment rules help consumers?
A. The new rules allow insurers to accept partial payments within a $5 threshold, preventing coverage lapses due to small unpaid amounts.
Q4: What changes are being made to the risk adjustment program?
A. CMS plans to update risk adjustment models with 2020-2022 data and adjust coverage for Hepatitis C and HIV drugs.
Conclusion
CMS’ proposed ACA marketplace rules for 2026 reflect a comprehensive effort to address fraud, improve agent accountability, and protect consumers. With updates to premium payment policies, risk adjustment models, and drug cost adjustments, CMS aims to create a more reliable and secure healthcare exchange. Stakeholders are encouraged to participate in the public comment process to ensure the final rules reflect a broad range of perspectives.
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