CMS Tightens Reins on Obamacare Access

 The Trump administration announced a plan to curb Affordable Care Act (ACA)-related spending by beefing up income verification for subsidies, tightening open enrollment periods, and eliminating access for some young immigrants.

"We are strengthening health insurance markets for American families and protecting taxpayer dollars from waste, fraud, and abuse," said HHS Secretary Robert F. Kennedy Jr. in a statementopens in a new tab or window regarding the new guidance, known as the "Patient Protection and Affordable Care Act; Marketplace Integrity and Affordability Final Rule.opens in a new tab or window"

During the COVID-19 pandemic, eligibility for ACA premium subsidies extended to cover the entire premium for those with incomes between 100% to 150% of the federal poverty level. "CMS believes this temporary expansion of premium subsidies resulted in conditions that were exploited to improperly gain access to fully-subsidized coverage," the agency noted in a fact sheetopens in a new tab or window.

Some 5 million people might have been improperly enrolledopens in a new tab or window, costing the healthcare system as much as $20 billion, the agency said, citing research from the Paragon Health Instituteopens in a new tab or window.

Under the final rule, CMS said it is taking the following steps to address these enrollment issues:

• Eliminating the monthly special enrollment period (SEP) for those whose estimated household income is at or below 150% of the federal poverty level
• Requiring income verification to ensure people are eligible for premium subsidies they receive
• Enacting eligibility verifications for most enrollments during SEPs and getting rid of avenues that let people enroll in plans only after they need care
• Requiring a $5 premium from anyone receiving the advanced payments of the premium tax credits who is auto-enrolled in fully-subsidized plans on the federal exchange

By implementing a "$5 premium responsibility," CMS argued it can reduce improper enrollments in the marketplace and prevent marketplace coverage from continuing for anyone unaware of their enrollments.

With regard to income eligibility, CMS plans to reinstate a 2015 policy that calls for the exchanges to deem an individual ineligible for premium tax credits if that individual, or person filing their taxes, did not file their income taxes and "reconcile" those tax credits for 1 year, rather than 2 years, as specified in a 2024 payment notice.

Additionally, the final rule seeks to standardize and shorten the annual open enrollment period (OEP), with the exchanges having flexibility to determine their own enrollment periods within certain limits.

"Each OEP must start no later than November 1 and end no later than December 31, and the OEP may not exceed 9 calendar weeks," a CMS fact sheet said. Open enrollment previously extended from November 1 to January 15 in most states.

By standardizing the open enrollment period, CMS hopes to encourage consumers to maintain year-round coverage, the agency said. And by "closing loopholes" that let people enroll when they decide they need care, the administration believes it can lower premiums for middle-class families due to the healthier risk pool, the press release stated.

The final rule announced on Friday, which goes into effect in the 2026 plan year, excludes Deferred Action for Childhood Arrivals (DACA) recipients, also known as "Dreamers," from enrollment in ACA coverage by amending the definition of "lawfully present" for eligibility and enrollment in exchanges and basic health programs to exclude them, undoing provisions of the 2024 DACA Ruleopens in a new tab or window, the fact sheet noted.

DACA recipients across nearly half of the country were already barred from enrolling in ACA coverage or accessing ACA subsidies. In December, a federal judge in North Dakota blocked accessopens in a new tab or window to ACA enrollment for Dreamers when he sided with the 19 states that sued the Biden administration over the rule.

An estimated 725,000 to 1.8 million people could lose coverage as a result of the rule's provisions, the agency said.

Many of the policies aimed at stopping improper enrollments are temporary and will sunset at the end of the 2026 plan year, CMS noted.

CMS Administrator Mehmet Oz, MD, praised the administration and his own agency's efforts.

"This is about putting patients first, stopping exploitation of the system, and realigning the program with the values of personal responsibility and fiscal discipline," he said.

https://www.medpagetoday.com/washington-watch/washington-watch/116208