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  • Washington Highlights

    CMS Issues Final HHS Notice on Benefit and Payment Parameters for 2019

    Kate Ogden, Physician Payment & Quality Specialist

    The Centers for Medicare and Medicaid Services (CMS) April 9 issued a final rule on benefit and payment parameters included in the Affordable Care Act (ACA, P.L. 111-148 and P.L. 111-152). The final rule includes 2019 payment parameters and additional guidance related to other key provision of the ACA, such as essential health benefit (EHBs) and qualified health plan (QHP) standards, risk adjustments, and hardship exemptions.

    CMS clarified that this final rule is intended to advance the current administration’s goals of increasing flexibility, improving affordability, strengthening program integrity, empowering consumers, promoting stability, and reducing unnecessary regulatory burden in the individual and small group health insurance markets.

    In the final rule, CMS released new guidance on hardship exemptions that expanded exemptions to allow individuals who live in counties with no health insurance issuers or only one issuer to be exempt from paying the ACA’s penalty for not holding health care coverage. Additionally, CMS published a bulletin that expands the transitional policy for one year, allowing individual and small group health insurance markets to delay their full compliance with ACA coverage policies until 2019.

    CMS also finalized additional policies that provide states with greater flexibility and control, including:

    • States are offered more options in what they can choose as an EHB-benchmark plan.
    • Standardized options/differential displays of standardized options on healthcare.gov will not be encouraged.
    • States hold an expanded role in the QHP certification process, and CMS will continue to defer to state’s network-adequacy standards.
    • The meaningful difference requirement for QHPs is eliminated.
    • State exchanges will be able to make a determination of lack of affordable coverage based on projected income using the lowest cost exchange metal level plan offered through the Exchange, when there is no bronze level plan in the service area.

    In an effort to strengthen program integrity, CMS will generate annual income inconsistencies for consumers who attest to an income that is higher than the amount found in data received from the exchange’s data sources. CMS clarified that this check will only be for households for which these data sources reflect income below 100 percent of the federal poverty level, because eligibility information will be used to determine whether households at this income level will receive the premium tax credit. Additionally, exchanges are no longer prohibited from discontinuing the premium tax credit payment to individuals who have failed to file a tax return.

    CMS also finalized changes to the HHS-Risk Adjustment Data Validation (HHS-RADV) requirements in an effort to ensure integrity of results and reduce unnecessary regulatory burden on insurers.