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New CMS resources help states waive ACA requirements

Most states have gotten or are seeking the waivers to establish a reinsurance program to reimburse insurers that are covering high claim costs.

Susan Morse, Managing Editor

The Centers for Medicare and Medicaid Services has released new resources to help states submit waivers to Affordable Care Act requirements.

The resources are to identify areas of flexibility and variations states can consider, such as combining multiple waiver concepts or coming up with their own.

Most states have gotten or are seeking the Section 1332 waivers to establish a reinsurance program to fully or partially reimburse insurers that are covering claims for high-risk beneficiaires. This reduces the price of premiums in those states.

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States that have approved 1332 waivers are Maine, Wisconsin, Minnesota, New Jersey, Maryland, Oregon, Alaska and Hawaii, according to a Kaiser Family Foundation report.

States may waive seven ACA requirements, including: the individual and employer mandates to have health insurance; essential health benefits; limits on cost sharing for covered benefits; metal tiers of coverage; requirements for marketplaces to have a website, call center and a navigator program; and premium tax credits and cost-sharing reductions.

An ACA requirement that remains in place is preserving access to coverage for people with pre-existing conditions. Other guardrails mandate that the new plan provide coverage that is at least as comprehensive in covered benefits, at least as affordable and cover a comparable number of residents.

The new CMS resources include a checklist of required waiver elements and model templates to better navigate the waiver application process. States do not need to use the checklist or templates to apply for a waiver.


The Trump Administration touts the waivers as a way to make individual coverage more affordable than the ACA. Between 2013 and 2017, average premiums in states using doubled, CMS said. Insurers also began exiting health insurance markets in 2017 and 2018, before returning for 2019 when the market and premiums stabilized.

Critics see the seven waiver opportunities as an eroding of coverage protections.


New waiver concepts issued by the Trump administration in 2018 encourage states to make broader changes through greater flexibility to waive ACA requirements.

New approaches include restructuring the ACA's premium tax credit to make coverage more affordable for young and healthy enrollees, allowing tax credits to be deposited into consumer-directed accounts that can be used to buy a broader range of health insurance plans, and pursuing innovative strategies to address high-cost enrollees, CMS said.


"To date, the Trump Administration has approved seven reinsurance-type waivers that lowered premiums and strengthened insurance markets -- showing our strong commitment to help states achieve better results for their citizens," said CMS Administrator Seema Verma. "While states have tremendous opportunities to strengthen their health insurance markets through a State Relief and Empowerment Waiver, we've also heard from states that they need more help and detail from CMS in putting together their waiver applications."

Twitter: @SusanJMorse
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