CMS Issues Final Rules for Open Enrollment Starting in 2015

On Friday, CMS issued a final rule outlining standards for the exchange and health insurance market beginning in the 2015 open enrollment period under the Affordable Care Act, including changes to how navigators are regulated and increases to risk corridor payments, Modern Healthcare reports.

Details on Navigator Guidelines

The guidelines reduce states' abilities to regulate navigators by pre-empting state laws on such positions. According to the guidelines, CMS will pre-empt entire state laws, or parts of them, if they "prevent the application of the provisions of Title I of the" ACA. The agency said it is able to pre-empt the laws because "Congress made clear that while states continue to have authority to enact laws that affect programs established under the [ACA], that authority is not unlimited."

Further, CMS specified that it would not pre-empt state laws that do not prohibit navigators from completing their federal duties, such as measures that require navigators to register, pass background checks or complete state training. However, CMS will pre-empt laws that require navigators to refer consumers to insurance brokers or agents for help with choosing an exchange plan.

Details on Risk Corridor Guidelines

Meanwhile, the new guidelines finalize changes to the ACA's risk corridors provision.

Under the changes in the rule, the formula used to calculate insurers' payments will increase the cap on administrative costs by 2%. In addition, the profit margin floor will increase by 2% (Dickson/Demko, Modern Healthcare, 5/16).

While the Obama administration previously said such payments would be budget neutral, the rule notes that "in the unlikely event of a shortfall for the 2015 program year," HHS "will use other sources of funding" for the payments. It continued that the ACA requires the agency "to make full payments to issuers," but that funding for the payments would only be appropriated if needed and "subject to the availability of appropriations" (Viebeck, The Hill, 5/16).

Other Changes

Other changes to the exchange and insurance market included in the rule are:

• Lowering the threshold for reinsurance payments from $70,000 in consumer claims to $45,000 (Modern Healthcare, 5/16);
• Allowing state insurance commissioners to decide whether small businesses must use the delayed Small Business Health Options Program or if they can continue to offer just one employer-selected health plan to their workers;
• Stipulations for individuals looking to purchase fixed indemnity plans; and
• New requirements for consumer-assistance organizations that help people to enroll in exchange plans (Radnofsky, Wall Street Journal, 5/16).