The annual Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameter (NBPP) for 2019 proposed rule was released on October 27, 2017. It contains some eye-opening details about the future path of the Affordable Care Act (ACA). There have been many attempts this year to dismantle and drastically alter the course the ACA set out to achieve. The 2019 NBPP proposed regulations display the same message that has been heard all year – to make many changes to the foundational structure and administration process of the ACA.
At the onset of the ACA, the intent was for it to be a state-run program, not a federally-run program. The means to operationalize a State-Based Marketplace far exceeded the benefits. Many states opted not to stand up a Marketplace, and, by default, the federal Marketplace was utilized by the majority of the country. The proposed 2019 NBPP is putting more onus back onto the states for their involvement by allowing them to have flexibility in decision-making. One area of focus is to allow the states to establish Essential Health Benefits (EHBs) within their state. This proposed rule may have some difficulty being established because it goes against the foundational ACA law that was passed in 2010. The administration believes by having more state involvement in establishing EHBs and being involved in the rate setting certification process, the proposed changes will reduce unnecessary regulatory burden, empower consumers, and improve affordability.
Risk adjustment is seeing many proposed changes in an attempt to bring stability to an otherwise volatile market. There are proposed changes that impact the overall methodology, risk adjustment data validation (RADV) processes, and state involvement. Additionally, there are proposed adjustments around the eligibility of reinsurance. These stabilization programs that mitigate the risk taken by health plans, often referred to as “The 3 R’s,” have been a controversial topic across the industry and have not been adequately administered in prior years to provide the stabilization the commercial market needs. The proposed regulations set out to recalibrate the model and provide greater oversight of the integrity of the data being submitted.
The Centers for Medicare & Medicaid Services (CMS) is seeking comments regarding the proposed regulations no later than 5:00 pm ET on November 27, 2017.
This new industry brings about greater challenges than we’ve ever known in government programs while also providing immeasurable opportunities for health plans that prioritize high quality, clinical care, as well as proper coding and documentation and highly functioning enrollment and reconciliation functions. GHG has first-hand knowledge of vital plan operations and provides comprehensive strategies across a full spectrum of business needs. Visit our website to learn more >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>