The Department of Health and Human Services (HHS) has released a proposed rule that, if finalized, will require federal and state-based Exchanges to conduct more frequent checks to verify enrollee eligibility for premium tax credits, cost-sharing assistance, and Medicaid. Individuals would also be able to authorize Exchanges to automatically terminate coverage once the individual becomes eligible for Medicare. Finally, health plans that offer coverage for abortion services, and which are required to bill individuals separately for that coverage, would be required to send two separate bills and receive two separate transactions from the individuals for the premium and additional abortion service coverage.

Exchanges are the platform used to enroll in health plans offered to individuals under the Affordable Care Act (ACA). The changes are proposed under the umbrella of increasing program integrity, but will likely have the impact of more quickly removing an enrollee’s eligibility for subsidies, possibly jeopardizing their health coverage status. The proposed additional billing requirements for abortion services will likely further discourage health plans from offering coverage for the services.

These proposals come on the heels of previous decisions to strengthen the qualifications for special enrollment periods outside of open enrollment, and the requirement that some individuals produce documentary evidence if a consumer attests an income that is significantly higher than the amount in the income data available to the Exchanges. If finalized, the changes will not take effect until 2020.

Comments on the proposal are due Tuesday, January 8, 2019.

Federal Oversight of State-Based Exchanges May Increase

HHS is proposing to increase federal oversight of State-Based Exchanges (SBE), specifically the activities that the SBE uses to determine individual eligibility for advanced premium tax credits (APTCs) and cost-sharing reduction payments (CSRs). Beginning in 2020, SBEs would be required to conduct data matching on enrollees at least twice a year. SBEs would also be required to conduct and submit results of testing of SBE eligibility and enrollment as part of the annual programmatic audits.

Individuals Would be Able to Authorize Exchanges to Terminate Coverage Once the Individual Becomes Eligible for Medicare or Medicaid

Individuals that are eligible to receive Medicare Part A benefits without a premium, or who are enrolled in Medicare Part B or Medicare Part C are not eligible to receive APTCs or CSRs to help pay for an Exchange plan or covered services. HHS is proposing to, beginning in 2020, allow all enrollees, even those not receiving APTCs or CSRs to authorize the Exchange to request the information necessary from HHS to determine whether the consumer is simultaneously enrolled in Medicare and terminate coverage if the enrollee is in fact eligible for Medicare. Exchanges would still be required to notify enrollees of the termination and provide a 30-day period for the enrollee to respond.

HHS states that the agency believes that “many” individuals are inadvertently enrolled in both Medicare and an Exchange health plan, and that most of these individuals have aged into Medicare during the year. Individuals who receive APTC or CSRs after they become eligible for Medicare coverage are liable for those payments when they file their income tax returns. HHS also states that moving individuals eligible for Medicare and Medicaid/CHIP more efficiently out of the Exchange market may create a “more balanced” risk pool.

Plans Would be Required to Send Separate Bills, Collect Separate Payments for Abortion Services

This proposal would require health plans that cover abortion services that are excluded from subsidized coverage to send an entirely separate monthly bill to individuals in order to collect the separate payments for the coverage. Enrollees would also be required to make a separate payment to the plan for the coverage. Currently, rules allow plans to send one bill and individuals to make one payment, with the breakdown between the two coverages included on a single bill.