On February 6, 2020, the U.S. Department of Health & Human Services (HHS) published its annual draft rule governing core provisions of the Affordable Care Act (ACA), including the operation of the marketplaces, standards for individual and small-group market health plans, and premium stabilization programs. This expert perspective focuses on several policies that would have implications for state insurance regulation and the operation of the state-based marketplaces (SBMs). Comments on the rule are due March 2, 2020.

As we round out the seventh year of ACA open enrollment, State Health and Value Strategies (SHVS) is reflecting on the successful steps that states have taken to provide quality, affordable health coverage to more residents and draw on lessons learned as this work moves forward.  SHVS is excited to launch a series of posts featuring policy and outreach strategies states are employing to meet the needs of their residents. This Expert Perspective highlights some of the key ways in which states are driving efforts to increase enrollment this past open enrollment period. Subsequent posts will include deep dives into certain specific state policies and outreach strategies, such as plan standardization and targeted outreach to address health disparities in coverage.

In 2019, the Washington legislature enacted a bill requiring insurers on the state’s health insurance exchange to offer plans with standardized benefit designs, beginning in 2021. Colorado and Maryland are considering similar requirements. As these and other states consider the option of standardized health plans, they can benefit from the experiences of California, the District of Columbia (D.C.), Connecticut, Massachusetts, New York, Oregon, and Vermont, all of which require insurers to offer standardized benefit designs. This Expert Perspective outlines benefits and risks of plan standardization, and raises critical questions that states will need to consider, and offers a decision roadmap for states implementing a standardized benefit design requirement.

On October 4, the President issued a proclamation that requires immigrants to show that they have health insurance or can pay medical expenses out of pocket in order to receive a visa. The proclamation will impact individuals applying for a visa with the Department of State (DOS) through consular offices abroad. In this expert perspective, Manatt Health reviews this latest policy regarding uninsured noncitizens and provides their take on implications for states.

In recent months, states have increasingly introduced proposals for individuals above Medicaid eligibility levels to “buy-in” to Medicaid or leverage the Medicaid program to strengthen coverage across the individual market and Medicaid. State Health and Value Strategies is tracking current state activity and has mapped out which states are pursuing a program and those that are establishing task forces to understand the impact of a Medicaid buy-in program.

On March 27, for the second time, a federal judge vacated the Centers for Medicare & Medicaid Services (CMS) approval of Kentucky’s Medicaid 1115 demonstration waiver to test, among other things, a work requirement as a condition of Medicaid eligibility. In a related case of Arkansas’s Medicaid work requirements demonstration, the judge likewise vacated the federal approval, remanding it to CMS for further consideration. Notably, because Arkansas, unlike Kentucky, had already implemented the work requirements, the decision requires the state to cease its work requirement and related Medicaid disenrollments. This expert perspective reviews the court’s decision and its implications for both Kentucky and Arkansas and other states with similar approved or pending waiver requests, as well as for states contemplating imposing work or other “community engagement” requirements on Medicaid beneficiaries.

President Trump issued an executive order on October 12, 2017 to encourage the expansion of association health plans (AHPs) for small businesses and the self-employed. On June 19, 2018 the U.S. Department of Labor (DOL) released a final regulation to implement that order. The final rule is similar to a draft version that the administration issued in January 2018. The new AHP policy raises numerous issues affecting state regulators, insurance markets, and the consumers and small businesses who buy coverage.

Several recent federal court decisions have held that the federal government owes insurers billions in cost-sharing reduction (CSR) payments. The Administration cut off those payments in October 2017, after efforts to repeal the Affordable Care Act (ACA) failed in Congress. Insurers promptly sued, arguing that the government had breached its statutory obligation to compensate insurers for offering the mandated low cost-sharing plans. Of note, the court decisions suggest that the government continues to owe these CSR payments even though most insurers were able to mitigate their losses by increasing plan premiums in 2018 and beyond. Because this litigation is almost certain to carry over into 2020 or beyond, this Expert Perspective post suggests that states not change their approach to insurers’ rating practices for 2020. However, states should consider what their approach should be if insurers do prevail in the litigation and states have an opportunity to recoup what otherwise would be a windfall for insurers.

Following guidance released earlier this fall, on November 29, 2018 the Centers for Medicare & Medicaid Services (CMS) released a discussion paper entitled “Section 1332 State Relief and Empowerment Waiver Concepts” to provide states with additional guidance and information about four types of waiver concepts that could be approved under the earlier guidance. This expert perspective reviews the four waiver concepts proposed in the discussion paper and the potential opportunities they present for states.

On November 9, 2018, the U.S. Department of Health & Human Services (HHS) published a proposed set of new standards for the Affordable Care Act (ACA) marketplaces. The preamble describes these standards as part of HHS’ efforts to improve marketplace “oversight and financial integrity.” If finalized, they will be effective for the 2020 plan year. HHS is asking for comments on the proposal by January 8, 2019.