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CMS final rule requires ACA insurers to collect separate payment for abortions

Rule would pertain to 18 states that have health plans that offer coverage of non-Hyde abortion services.

Susan Morse, Managing Editor

The Centers for Medicare and Medicaid Services has issued an Exchange Program Integrity Final Rule that includes a requirement for insurers to send a separate bill to members for abortion services.

CMS is requiring health plans on the exchanges to send a separate bill and attempt to collect separate payments for the portion of consumers' premiums attributable to certain abortion services for which public funding is prohibited.

The law prohibits federal funding for coverage of non-Hyde Amendment abortion services, that is, except in the case to save the life of a woman, or if the pregnancy arises from incest or rape.

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CMS estimates that 18 states currently have health plans that offer coverage of non-Hyde abortion services.

The rule aligns with Congress' intent for insurers to collect two distinct payments, one for the coverage of non-Hyde abortion services, and one for coverage of all other services covered under a qualified health plan, CMS said.


America's Health Insurance Plans said it had serious concerns with requirements that create a more complex and confusing consumer experience, impose new costs on consumers and which could increase premiums by imposing new costs on health insurance providers.

Plans offered on the individual marketplace for 2020 are final at this point, including those offered on the and on state-based exchanges.

"Moving forward, insurance providers will continue to develop and offer comprehensive benefits and plans that help care for the whole person. When health insurance providers develop their plan offerings for the year, they are required to comply with both state and federal laws, including state mandates and benchmark benefits," AHIP said. "Insurance providers will work to incorporate required changes as outlined under the final rule and are committed to minimizing consumer confusion."

The Associaton for Community Affiliated Plans expressed concern that the administrative burden of the rule would cause plans to drop abortion coverage.

"Healthcare is complex enough as it is. Requiring people to pay two bills for one product--health coverage--is a non-solution in search of a problem. This misguided rule will only succeed in introducing confusion to the marketplace on a massive scale, and put millions of consumers at risk of losing their coverage," said ACAP CEO Margaret A. Murray. "Failing to pay both bills every month will set consumers on a path to total termination of coverage. It's hard to think of another industry where the government mandates, as the Trump administration would here, that consumers cut two checks a month for the same service. What's worse, ACAP expects that the administrative burdens this rule will impose on issuers and consumers will lead plans to drop abortion coverage--even if their enrollees desire such coverage."

CMS said its requirement ensures that taxpayers do not contribute funds to pay for coverage of abortion services for which funding isn't allowed by law, and will alert consumers that their health plan covers abortion services, allowing them to make fully informed decisions about their coverage, CMS said.

The separate billing requirement in the final rule become effective June 27, 2020.


Another part of the final rule becomes effective within 60 days. This is a new requirement that state-based exchanges conduct regular eligibility verifications with outside data sources at least twice a year.

States are being required to confirm that they are correctly identifying eligible enrollees, including those who qualify for tax credits and cost-sharing reductions. Specifically, state-based exchanges are required to conduct and submit the results of annual programmatic audits.

The rule also implements, for both state and federal exchanges, enhanced periodic data matching that will allow CMS to more frequently identify and resolve issues related to consumers who are dually enrolled in both Medicare and an ACA health plan.

Beginning with plan year 2020, CMS will require state-based exchanges to conduct Medicare, Medicaid/CHIP, and as applicable, basic health plan periodic data matching at least twice a year for enrollees who receive subsidies.


The Affordable Care Act and health plans on the exchanges have experienced myriad issues since the inception of the ACA, but this year, premiums or their increases have decreased and insurers have jumped back into the market.

As the market has stabilized, however, the number of those signing up for coverage had dropped by 10% as of the end of Week 5 of open enrollment and the legal examination over the legality of the ACA lingers.

The Fifth Circuit Court of Appeals this week kicked the question of the validity of the law without the individual mandate back to the district court in Texas. ACA coverage for 2020 remains.

In addition, Alex Azar, the secretary of the Department of Health and Human Services, and CMS Administrator Seema Verma are reportedly at odds to the point that Vice President Mike Pence intervened last week, according to The Washington Post.

Verma's case has not been helped by leaks that she spent close to $3 million in taxpayer money to contractors to help boost her own brand, the report said.


HHS Secretary Alex Azar said, "Providing these separate bills is an essential step in implementing the Affordable Care Act's bar on tax credits going toward coverage of abortions for which public funding is prohibited. The separate billing requirement fulfills Congress' intent and reflects President Trump's strong commitment to preventing taxpayer funding of abortion coverage."

"Our healthcare programs, including the exchanges, are evolving rapidly, and our program integrity efforts must keep up," said CMS Administrator Seema Verma. "Today's final rule drastically improves our ability to pay it right--to make the right payment to the right plan for the right people. The Trump Administration will spare no effort to ensure that taxpayer dollars are only going to those truly eligible."

Twitter: @SusanJMorse
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