April 19, 2019



In This Issue
Fast Facts
CMS Finalizes 2020 Payment Parameters Rule and Letter to Issuers
Congress is Back in District – Time to Meet Your Member!
Join the Conversation as a Member of a NAHU Legislative Council Working Group
State Spotlight: Comprehensive Surprise Billing Legislation Makes Its Way through Texas
Healthcare Happy Hour: Now Available on Spotify!
Register for Next Week’s Webinar on the State of the Long-Term Care Insurance Industry
Did You Miss Yesterday’s Webinar on Compliance Questions?
Register for the Catalyst for Payment Reform’s Virtual Event on May 17
HUPAC Roundup: Swinging in the Midwest
What We're Reading
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CMS Finalizes 2020 Payment Parameters Rule and Letter to Issuers
On Thursday, CMS released its final 2020 Notice of Benefit and Payment Parameters and Letter to Issuers. NAHU submitted comments on both of the proposals in February. The 401-page payment parameters final regulation provides guidance on changes to the marketplace user fee, calculations for premium tax credits, prescription drugs as part of the “America First” initiative, navigator and broker roles, enhanced direct enrollment and the risk-adjustment program, among other issues. The 21-page letter to issuers is largely boilerplate from previous years, and covers operational and technical guidance to issuers for participating marketplace insurers.

Major changes include:
  • The Marketplace user fee will be reduced to 3.0% for the federal Marketplace and to 2.5% for state-based exchanges on the federal platform.
  • The formula for determining premium tax credits will now use a blend of premiums from the individual market and employer-sponsored plans to calculate financial assistance. This was prompted by the additional subsidies paid as a result of insurers “silver loading” or increasing premiums to offset losses as a result of the Trump Administration’s decision to terminate funding for the cost-sharing reduction program. It is expected that this will increase rates and the portion of income contributed to premiums for some enrollees due to an increase in the Health Insurance Tax paid by most issuers. It is projected that changing the formula will result in $980 million less in federal financial assistance and 70,000 fewer enrollees.
  • It modifies the duties and training requirements for navigators to reduce burden, increase flexibility and enable exchanges to more easily and cost-effectively operate navigator programs. Navigators will be authorized but not required to provide certain types of assistance, including post-enrollment assistance. NAHU commented heavily on this provision because of the limited training and education navigators receive.
  • It provides greater flexibility for direct-enrollment entities and additional oversight and transparency. Web brokers will be required to provide the agency with a list of brokers and agents that use their platforms.
  • It finalized changes to add definitions of “direct enrollment technology provider,” “direct enrollment entity,” “direct enrollment entity application assister” and “web broker.” Previously these terms were used interchangeably or, in most cases, all of these entities were referenced as web brokers.
  • It finalized several changes to reduce the cost of prescription drugs as part of the “American Patients First” initiative. Insurers will be permitted to exclude manufacturer coupons from counting towards patients' annual limitation on cost sharing if a medically appropriate generic drug is available. This applies to the individual market, small-group, large-group and self-insured group health plans.
  • It did not finalize changes that would have allowed insurers to not count other kinds of cost-sharing toward a patient's annual out-of-pocket limit if the beneficiary insisted on a brand-name drug when an appropriate generic was available.
  • It did not finalize the proposal to allow insurers to adopt mid-year formulary changes to incentivize greater use of generic medicines.
Additionally, the guidance noted that it received comments on potential future changes to cost-sharing reductions and reenrollments, both of which NAHU commented on. It noted that the Administration supports a legislative solution to appropriate CSR payments and end silver loading, but will not take action until the 2021 plan year, at the earliest. It also noted concerns with re-enrollment for consumers updating information in a timely manner. NAHU Advised CMS to discontinue its policies of reenrollments and redeterminations and strongly suggested prohibiting auto-reenrollment.
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