Groups representing both insurers and providers have told the Centers for Medicare and Medicaid Services they're pleased the agency is not currently ending the practice of silver loading for health plans in the Affordable Care Act market.
In comments on a proposed rule on benefit and payment parameters for 2020, the American Hospital Association often cited needed health plan cooperation in issues raised by CMS on transparency and interoperability.
AHIP recommends that the Department of Health and Human Services not implement major policy changes for the 2020 plan year in the final rule because of the later than usual timeline for publication of the proposed payment notice.
"Health insurance providers will be in the end stages of finalizing products and rates for the 2020 plan year when the final rule is published," AHIP said. "At that late stage it will be difficult for insurance providers to adapt product offerings to accommodate significant policy changes."
In the proposed rule, CMS said it wanted input on the possibility of ending silver-loading. Under silver-loading, insurers apply the full premium increase to silver plans in the Affordable Care Act marketplace. The government, and not most consumers, end up paying the bill as the majority of ACA consumers get federal subsidies for coverage.
HHS Secretary Alex Azar allowed silver loading, at least for 2019, to help insurers make up for the loss of cost-sharing reduction payments, which ended under the Trump Administration.
AHIP supports continuing silver loading absent an appropriation by Congress to fund the CSRs.
The AHA also supports the practice and congressional action to fund the CSRs. Without silver loading or CSRs, plans pass the costs onto consumers through higher premiums, which threatens access to covered care, said the AHA's Executive Vice President Thomas P. Nickels.
Surprise medical bills are an area for insurer improvement, according to the AHA. The association is urging CMS to increase oversight and enforcement of health plan provider network and directory standards, saying they are often out-of-date or missing information. Also, the AHA said there are instances in which health plans report to have in-network certain hospital-based specialists only for consumers to find out that none of the network specialists practice at the in-network hospitals.
Simply having accurate provider directories will not fully protect patients, the AHA said. CMS should ensure that plans have taken into account whether the in-network physicians practice at the in-network facilities.
CMS is mandating that hospitals post price information, but providers often lack more detailed cost-sharing information that health plans could provide, the AHA said. Plans are often unwilling to disclose the negotiated rates in contracts between the hospital and health plan in advance of providing care, but doing so would help negate any surprises for patients, the association said.
Health plans' response often is limited to "yes/no" about whether the individual is covered for the service, the AHA said. At that point, hospitals and health system staff must rely on a more manual process – calling the health plan for a one-on-one discussion about a patient's coverage.
"This is not a scalable solution if the objective is to promote widespread access to timely, accurate and personalized cost-sharing information," Nickels said.
"While the health plans provide this same information to the patient after the procedure through the explanation of benefits, they are not allowing patients to obtain this information prior to the procedure, handicapping price transparency efforts."
Most hospitals and health systems make records available to patients online and 88 percent regularly share records with ambulatory care providers outside of their system, the AHA said. It's the health plans that have access to a more complete picture of the services received than any individual healthcare provider.
The AHA and six other national hospital associations are calling for connecting information beyond EHRs, such as patient generated data and claims information. The organizations recently released a report, Sharing Data, Saving Lives: The Hospital Agenda for Interoperability.
Both AHIP and the AHA are against proposed changes to the premium adjustment percentage. CMS proposes to change the methodology for calculating the premium adjustment percentage to include individual market premiums in the calculation.
Currently, CMS calculates the premium adjustment percentage using employer-sponsored insurance premiums. CMS said it is proposing this change to more accurately reflect premium trends across all private health insurance markets.
AHIP said it would make coverage less affordable for consumers and result in coverage losses, citing HHS projections that enrollment through the exchanges would be reduced by 100,000 people in 2020. Premium tax credits would also be affected. As a result, the federal government would spend $900 million on subsidies to make coverage more affordable for low-income Americans, said Keith Fontenot, AHIP's executive vice president of Policy and Strategy.
"The proposed change would negatively impact the individual market and we strongly oppose it," Fontenot said.
The AHA said the marketplace has begun to demonstrate signs of stability, and this change could undo this progress by creating a cost barrier for consumers.
USER FEE AND RISK ADJUSTMENT
AHIP said it greatly appreciates HHS' proposal to reduce the user fee rates for health insurance providers on the exchanges for the 2020 plan year.
"We further recommend HHS reallocate user fee funds to re-invest in consumer outreach, education, and marketing for open enrollment," Fontenot said.
AHIP also supports the proposal to continue recalibrating the risk adjustment model based on EDGE data -- which reflects the actual data from insurers individual and small-group populations. In addition, AHIP supports maintaining the categories included in the risk adjustment model for the 2020 benefit year while adding a pricing adjustment to more accurately reflect changing drug prices.
But AHIP said it has serious concerns with the proposal to make EDGE data publicly available via a limited data set file.
"To safeguard commercially sensitive and proprietary data, we recommend that EDGE data should only be used for internal government purposes including administering the risk adjustment program and making updates to the actuarial value calculator," AHIP said.
To lower drug costs, the rule proposes allowing individual, small group, and large group market health insurers to adopt mid-year formulary changes. This is aimed at giving enrollees incentives to use of lower-cost generic drugs.
The AHA supports allowing plans to make mid-year changes to their formularies if a generic-equivalent becomes available.
AHIP said the proposals in the rule are worded very narrowly and could have the unintended consequences of precluding several other standard practices to reduce spending on drugs.
"We disagree with the assertion that current uniform modification rules prohibit mid-year formulary changes," AHIP said.
HHS should clarify that the policies proposed are not intended to limit the flexibility that health insurance providers currently have. If the changes are finalized, AHIP recommends HHS broaden the description of instances in which health insurers can employ the practices proposed in the rule and clarify that nothing would preclude payers from continuing current formulary practices.
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