…diagnosis, treatment, and follow-up care (including supplies, appliances and devices).” Both the ADA and the CDA also recommended a required dental loss ratio (often referred to as a DLR), similar to a medical loss ratio (MLR), to ensure dental plans spend a minimum share of premium dollars on dental care rather than administrative costs and profits. Other comments, however, asked…
…in Marketplace coverage. Special enrollment periods When consumers enroll on the FFM through a special enrollment period (SEP)—a mid-year enrollment opportunity triggered by the loss of coverage or another “qualifying life event”—coverage starts at the beginning of the month immediately following the enrollment date. Currently, some SBMs delay coverage effective dates if enrollment occurs in the latter half of the…
…to require that transitioning states document how they would make up for enrollment losses, if they decline to use the Enhanced Direct Enrollment (EDE) functionality that now drives much of HealthCare.gov’s enrollment. Network Standards Health insurance companies were less welcoming of proposals to raise the bar for Marketplace plans by extending the federal Marketplace’s network adequacy standards to insurers participating…
…continue to be considered EHB, and there would be no defrayal requirement. HHS argues that this change will make the identification of benefits in addition to EHB “more intuitive.” The agency acknowledges that there are states that may have been defraying the costs of benefits under the current policy that would be able to stop if this proposal is finalized….
…financial assistance will be key to protecting coverage gains. Looking ahead, policymakers will need to consider an extension of the Inflation Reduction Act’s enhanced Marketplace subsidies to avoid significant coverage losses after plan year 2025. Rebecca Silliman, Erin McNally, Cruz Vargas-Sullivan, and David Schleifer, Searching for In-network Mental Health Care with Marketplace Insurance, Public Agenda. Between October 11–November 14, 2022,…
…in bronze or gold plans. While modeling suggests that resulting coverage losses would be small, this concern has prompted Oregon to consider ways to mitigate the higher premiums for affected enrollees. State Fiscal Impacts The cost of a BHP to the state depends in part on the generosity of the coverage provided. But the cost also depends on how the…
…plans that small employers purchase come with low attachment points for stop-loss coverage. Since the employer pays a monthly amount to the stop-loss issuer that resembles a premium, they may not realize they have become the sponsor of (and taken on the fiduciary duties for) a self-funded plan. The NAIC has documented several consumer protection concerns associated with level funding arrangements, including…
…millions of Americans will lose Medicaid and experience higher Marketplace premiums, and the currently record-low uninsured rate is expected to increase. Despite efforts to reduce coverage loss during the unwinding of continuous Medicaid, CBO projections suggest those may be insufficient to stem coverage losses. Further, the estimates are a wake-up call for policymakers to start planning for the end of…
…legislation: High health care costs are driving many small employers out of the fully insured group market and into “level-funded” health insurance arrangements. These products combine a self-funded health plan with a stop-loss insurance policy. An estimated 35% of covered workers in small firms are now in a level-funded health plan. In general, self-funded employer plans purchase stop-loss insurance to…
By Sabrina Corlette, Rachel Swindle, and Rachel Schwab The Affordable Care Act (ACA) established health insurance Marketplaces (or “Exchanges”) to facilitate enrollment in comprehensive and affordable health insurance plans. The ACA envisioned that the Marketplaces would be primarily state-run, with the federal government stepping in as a backstop. In practice, due in part to deep anti-ACA sentiment among some state…
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