CMS Finalizes Sweeping Exchange Rule
The Centers for Medicare and Medicaid Services (CMS) finalized its sweeping 2027 Affordable Care Act and Exchange rule today. While a few items were not finalized, most of the major items that will dramatically change offerings were.
The agency says the rule is an effort to bring down premiums, increase choice, and address fraud. Critics say it will erode enrollment and benefits.
The changes include:
- Policies for tighter eligibility verification requirements, reformed marketing and enrollment practices, and fraud measures
- Extending a ban on a special enrollment period for those below 150% of poverty
- Expansion of access to catastrophic coverage due to hardship. This would apply to individuals who are ineligible for premium and cost-sharing reduction subsidies (those below 100% or above 250% of poverty) when they experience changes in their household income.
- Multi-year catastrophic coverage policies
- Value-based preventive benefits in multi-year coverage that will be covered pre-deductible.
- Non-network plans can qualify as essential benefit plans
- Changes to cost-sharing parameters to increase flexibility for issuers designing individual bronze and catastrophic plans.
- Repeal of standardized benefit options and no limits on non-standardized plans
- States get greater authority over plan oversight
- Lower user fees on plans to lower premiums
- Beginning in plan year 2028, states will be required to defray the cost of benefits they mandate that are in addition to essential benefits.
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#exchanges #aca #obamacare #trump #regulations #coverage #healthcare
https://www.modernhealthcare.com/politics-regulation/mh-cms-aca-exchange-rule-2027-final
Plans, Providers Want A Targeted Fraud Approach
In response to a request for information on stemming fraud in government programs, providers and payers are each urging some caution.
Providers say the Centers for Medicare and Medicaid Services (CMS) should move cautiously to implement its anti-fraud strategy rather than apply a uniform approach across the board. They want reforms focused on high-risk activities so as not to further burden providers.
Hospital and physician groups do not want the claims deadline shortened from one year. If the window is shortened it should only apply to high-risk providers for whom there is clear evidence of fraudulent billing. However, the Blue Cross Blue Shield Association, which represents Blues health plans, supports shortening the filing deadline to 90 days for high-risk services.
Providers and insurers expressed concern about significant changes to the preclusion list, such as requiring all providers to enroll in fee-for-service Medicare as a condition of participating in Medicare Advantage (MA). This could have impacts on networks and access.
Providers and plans urged CMS not to allow MA plans to suspend payments to providers based on suspected fraud. If that is done, it should be restricted to instances when there is credible evidence of fraud or other serious program integrity issues.
Providers and insurers also want a transparent AI regulatory framework, including human oversight before using the technology for its fraud oversight initiatives. Providers also want AI tools used in MA coding to be thoroughly evaluated.
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#fwa #cms #providers #healthplans
https://www.modernhealthcare.com/politics-regulation/mh-cms-healthcare-fraud-hospitals-insurance
— Marc S. Ryan
