CMS moves to shore up ACA insurance markets
Skip to main content
MDHC_Logotype_white
Subscribe
  • My Account
  • Login
  • Subscribe
  • News
    • This Week's News
    • COVID-19
    • Providers
    • Insurance
    • Government
    • Finance
    • Technology
    • Safety & Quality
    • People
    • Regional News
    • Digital Edition
    • Wyo. hospital offers bonus to healthcare workers willing to get vaccinated before summer
      Insurers spent more on lobbying as Congress debated ACA and COBRA subsidies
      Humana misrepresented Medicare Advantage costs by $200 million, OIG says
      Telehealth increases downstream care, study finds
    • Wyo. hospital offers bonus to healthcare workers willing to get vaccinated before summer
      Cleveland Clinic, Mayo Clinic lead hospitals pushing for COVID-19 vaccination
      Chronic disease wave looms post-pandemic
      Claudia Williams writing on whiteboard in a room filled with people during a planning session.
      Momentum returns for health information exchanges
    • Wyo. hospital offers bonus to healthcare workers willing to get vaccinated before summer
      Alaska tribal health groups distribute vaccine far and wide
      Some healthcare associations moving full steam ahead with conferences starting in summer
      COVID hospitalizations in Michigan top fall surge; Beaumont seeing nurse 'burnout'
    • Insurers spent more on lobbying as Congress debated ACA and COBRA subsidies
      BCBSA wants to cut racial gap in maternal care by half in five years
      BlueCrossBlueShield_06_03_07_0.jpg
      Blue Cross bosses pocket pay hikes
      UnitedHealthcare sees Q1 profits rise and other key earnings takeaways
    • Neva Fairchild
      Digital accessibility challenges remain for telehealth
      Healthcare workers in a triage dialysis center.
      Gaps in disaster preparedness leave patients at risk
      Billions spent on coronavirus fight, but what happens next?
      10% of prescription drugs make up majority of Medicare drug spending, study finds
    • Johnson & Johnson Q1 profit, sales jump, beat Street views
      Private equity's estimated healthcare spending halved in first quarter
      UH reports $54.7M operating income for 2020 despite significant COVID-related costs
      CMS issues new guidance to enforce price transparency rule
    • Dr. David Brailer
      Q&A: First ONC head Brailer's vision for information sharing
      Claudia Williams writing on whiteboard in a room filled with people during a planning session.
      Momentum returns for health information exchanges
      A case study in HIE consolidation
      Digital health funding hit $7.2B in Q1
    • Chronic disease wave looms post-pandemic
      Neva Fairchild
      Digital accessibility challenges remain for telehealth
      Healthcare workers in a triage dialysis center.
      Gaps in disaster preparedness leave patients at risk
      Michigan expands antibody treatment to cut hospitalizations
    • Tenet's general counsel to retire at end of year
      Oscar names new virtual-first care division president
      Redfield joins Big Ass Fans, which promotes controversial COVID-killing technology
      Next Up Podcast: Modern Healthcare's editor Aurora Aguilar talks new content direction
    • Midwest
    • Northeast
    • South
    • West
  • Insights
    • ACA 10 Years After
    • Best Practices
    • Special Reports
    • Innovations
    • The Affordable Care Act after 10 years
    • A close-up of a woman receiving a COVID-19 vaccine.
      Providers in underserved communities work toward equitable vaccine distribution
      Josh Bradshaw
      How one rural Illinois county vaccinated 84% of its senior citizens by early March
      Dr. John Fischer
      Patient-reported outcomes tool for hernia surgery helps physicians improve care
      New care model helps primary-care practices treat obesity
    • Arrows made of binary code.
      Collaboration across the C-suite key to implementing data blocking, interoperability rules
      A graphic that includes a man in a wheelchair and images of binary code.
      Post-acute facilities face hurdles in healthcare's interoperability push
      A family photo of the the Hangens.
      Stressing the already burdened pediatric behavioral health system
      Jennifer Pannone and her daughter Victoria.
      Mental health access for children needs attention
    • Ryan McGinnis
      Finding efficiencies in the OR using tech
      Dr. Daniel Hall
      UPMC pilots machine learning, telehealth to inform patient transfers
      A woman being recorded using her inhaler on a smartphone.
      Digital check-ins, connected inhalers help control asthma
      A phone screen showing the question, "Mary we hope this information was helpful and we'd like to keep guiding you. Are you interested in knowing when it's your turn to receive the vaccine?"
      Chatbots, texting campaigns help manage influx of COVID vax questions
  • Transformation
    • Patients
    • Operations
    • Care Delivery
    • Payment
    • Mayo Clinic launches two tech companies
      Diabetes patients at high risk for COVID-19 are managing conditions more effectively
      Nearly 1 in 5 Americans skipped care due to cost last year
      COVID-19 long-haulers need holistic treatment, providers say
    • Telehealth increases downstream care, study finds
      Amazon gives out $12M under next phase of AWS diagnostics development initiative
      Malpractice premiums peak in 2020, AMA survey shows
      A rendering of a cancer research institute at the University of Southern California that will include 5G.
      Healthcare providers determine how to best use ultrafast 5G
    • Hospitals face specialty pharmacy challenges with insurer competition
      Addressing long-standing barriers needed for mental and physical health integration
      A close-up of a woman receiving a COVID-19 vaccine.
      Providers in underserved communities work toward equitable vaccine distribution
      The waiting room of a Kaiser Permanente clinic at a Target location.
      Health systems revamp their approach to retail clinics
    • Payers, providers clash over telehealth reimbursement as Congress mulls changes
      When money talks. Why cash pay is becoming more popular
      CMS wants to bump pay for hospices, SNFs next year
      CMMI pauses new Direct Contracting model applications
  • Data/Lists
    • Rankings/Lists
    • Interactive Databases
    • Data Points
    • Health Systems Financials
      Executive Compensation
      Physician Compensation
  • Op-Ed
    • Bold Moves
    • Breaking Bias
    • Commentaries
    • Letters
    • Vital Signs Blog
    • From the Editor
    • Dr. Alan Kaplan
      The risks, rewards of taking organizations 'where they haven’t gone before'
      Wellstar CEO calls adapting for the pandemic her bold move
      Howard P. Kern
      Recognizing the value of telehealth in its infancy
      Dr. Stephen Markovich
      A bold move helped take him from family doctor to OhioHealth CEO
    • Paul Tufano
      Healthcare's most important prescription—empathy
      Drs. Hal Paz and Joshua J. Joseph
      Mobilized to fight the COVID crisis: a blueprint for community and academic partnerships
      Dr. Stephen Markovich
      Making sure we're aligned along the path to achieving inclusion
      Barry Ostrowsky
      Ending racism is a journey taken together; the starting point must be now
    • Reed Hartley
      Data is the key to repairing the nation's healthcare system
      Cassie Leonard
      Removing an obstacle that impedes IT interoperability and vaccination efforts
      It's time we fulfill the ACA's promise to broaden access to lower-cost drugs
      Five lessons for securing our children's future
    • Letters: Eliminating bias in healthcare needs to be ‘deliberate and organic’
      Letters: Maybe dropping out of ACOs is a good thing for patients
      Letters: White House and Congress share blame for lack of national COVID strategy
      Letters: VA making strides to improve state veterans home inspections
    • Sponsored Content Provided By Optum
      How blockchain could ease frustration with the payment process
      Sponsored Content Provided By Optum
      Three steps to better data-sharing for payer and provider CIOs
      Sponsored Content Provided By Optum
      Reduce total cost of care: 6 reasons why providers and payers should tackle the challenge together
      Sponsored Content Provided By Optum
      Why CIOs went from back-office operators to mission-critical innovators
  • Awards
    • Award Programs
    • Nominate
    • Previous Award Programs
    • Other Award Programs
    • Nominations Open - Top 25 Innovators
      Nominations Open May 10 - Top 25 Minority Leaders
      Nominations Open May 24 - Top 25 Emerging Leaders
    • 100 Most Influential People
    • 50 Most Influential Clinical Executives
    • Best Places to Work in Healthcare
    • Health Care Hall of Fame
    • Healthcare Marketing Impact Awards
    • Top 25 Emerging Leaders
    • Top 25 Innovators
    • Minorities in Healthcare
      • - Luminaries
      • - Top 25 Minority Leaders
      • - Minorities to Watch
    • Women in Healthcare
      • - Luminaries
      • - Top 25 Women Leaders
      • - Women to Watch
    • Excellence in Nursing Awards
    • Design Awards
    • Top 25 COOs in Healthcare
    • 100 Top Hospitals
    • ACHE Awards
  • Events
    • Conferences
    • Galas
    • Webinars
    • COVID-19 Event Tracker
    • emburse certify modern healthcare custom media webinar logo lockup
      Sponsored Content Provided By Emburse
      Webinar: Making it easy to manage costs
      virtualmed staff modern healthcare custom media logo lockup
      Sponsored Content Provided By VirtualMed Staff
      Webinar: Best practices for creating a successful telepsychiatry program
      telehealth visit man touching neck while speaking to doctor on computer
      Sponsored Content Provided By Accumen
      Webinar: How telehealth has evolved into a standard of care
      Webinar: Avoid interoperability penalties. Modern Healthcare. Sponsored by Hall Render
      Webinar: Avoiding interoperability penalties
    • Women Leaders in Healthcare Conference
    • Social Determinants of Health Symposium
    • Healthcare Transformation Summit
    • Leadership Symposium
    • Virtual Briefings
      • - Hospital of the Future
      • - Mental Health
      • - Patient Safety & Quality
      • - Strategic Marketing
      • - Virtual Health
      • - Workplace of the Future
    • Best Places to Work Awards Gala
    • Health Care Hall of Fame Gala
    • Top 25 Minority Leaders Gala
    • Top 25 Women Leaders Gala
  • Listen
    • Podcast - Next Up
    • Podcast - Beyond the Byline
    • Sponsored Podcast - Healthcare Insider
    • Video Series - The Check Up
    • Sponsored Video Series - One on One
    • Next Up Podcast: Managing the COVID-19 vaccination rollout with Dr. Gary Little
      Next Up Podcast: Modern Healthcare's editor Aurora Aguilar talks new content direction
      Dr. Chris DeRienzo
      Next Up Podcast: Building team spirit in the wake of COVID-19
      Mikelle Moore
      Next Up Podcast: Mikelle Moore on recognizing all hospital workers during the pandemic
    • Beyond the Byline: Kids' unchecked mental health needs pose long-term consequences
      Beyond the Byline: How COVID-19 has impacted hospital finances
      An older man sitting on a hospital bed with his back toward the camera.
      Beyond the Byline: Upcoding could explain why hospitals are increasingly billing for the most complex treatment
      Beyond the Byline: Insurers are betting on virtual-first plans as COVID-19 shifts care pathways
    • James garvert neustar healthcare insider podcast image
      Building on basics
      Healthcare Insider Podcast Episode Art - Premier
      Why Roger Weems and other consultants are leaving the big firms to join Premier
      James garvert neustar healthcare insider podcast image
      Outreach during COVID-19
      ann barnes healthcare insider podcast image
      Leading with intention to promote diversity and inclusion
    • The Check Up: Kevin Shimamoto
      The Check Up: Kevin Shimamoto of Valley Children's Hospital
      The Check Up: Dr. James E.K. Hildreth
      The Check Up: Dr. James E.K. Hildreth of Meharry Medical College
      The Check Up: Matt Eyles
      The Check Up: Matt Eyles of AHIP
      The Check Up: Dr. Tom Shanley
      The Check Up: Dr. Tom Shanley of Lurie Children’s Hospital of Chicago
    • ivana naeymi-rad one on one intelligent medical objects
      Video: Ivana Naeymi Rad of Intelligent Medical Objects
  • MORE +
    • Advertise
    • Media Kit
    • Newsletters
    • Jobs
    • People on the Move
    • Reprints & Licensing
MENU
Breadcrumb
  1. Home
  2. Government
August 29, 2016 01:00 AM

CMS moves to shore up ACA insurance markets

Bob Herman
  • Tweet
  • Share
  • Share
  • Email
  • More
    Print

    (Updated at 6:15 p.m. EDT)

    The CMS proposed rules Monday afternoon that would make several changes to the Affordable Care Act marketplaces and refine the law's risk adjustment, heeding calls from the health insurance industry.

    The proposed rules (PDF), which normally are released in November, come after weeks of intense scrutiny and uncertainty about the viability of the new ACA insurance exchanges. Aetna, Humana and UnitedHealth Group, which have bigger footprints in the employer and Medicare Advantage markets, all have announced major retrenchments for the 2017 season, which begins Nov. 1.

    One of the biggest changes involves the ACA's permanent risk-adjustment program. Lawmakers created risk adjustment to compensate plans for taking on sicker enrollees who have higher healthcare costs, thereby attempting to eliminate the incentive to cherry-pick healthier people.

    Starting in 2018, risk adjustment would factor in prescription drug data in addition to all the normal conditions and illnesses that are factored into someone's risk score. Health insurers have argued their members look healthier than they actually are because the program doesn't account for the medicines people are taking. But some risk-adjustment experts believe using drug data could create perverse incentives for doctors to write unnecessary prescriptions.

    The CMS said the change was worth pursuing while considering those concerns. “We sought to strike a reasonable balance between increasing predictive accuracy and reducing incentives for overprescription,” the agency said. “One way we sought to do so was by focusing on drugs for which guidelines on when they should be prescribed are clear.”

    Conditions that involve drugs that would be used for the updated risk adjustment include hepatitis C, HIV/AIDS, end-stage renal disease, diabetes and inflammatory bowel disease.

    Risk adjustment in 2018 also would account for “partial-year” members who enroll outside of open enrollment. Insurers have said people who enroll midyear have higher healthcare costs and therefore are riskier to cover.

    The CMS' proposals would alter several areas within the 2018 exchange plans as well. For example, the agency proposed three additional sets of standardized plans, called “simple choice” plans.

    Last year, the CMS proposed six standardized health plan options as a way to simplify shopping for consumers on the federally run marketplaces. For instance, each plan in each tier level has the same deductible and same annual limit on cost-sharing. However, plans are not required to offer standardized options. Insurers fought aggressively against the Obama administration's proposal, saying those types of plans would “stifle” their ability to create new benefits and products.

    The new standardized options for 2018 mostly were proposed to adapt with existing state cost-sharing laws, the CMS said.

    The rule also proposed that insurers must offer at least one silver-level and at least one gold-level health plan if they sell on the exchanges, which cater to individuals and small businesses. Premium and cost-sharing subsidies are tied to silver plans and pay 70% of medical costs on average. Gold plans are more comparable to employer-based health coverage, paying about 80% of costs on average.

    The CMS has already made several changes to the exchanges in the past year, notably to tighten up when people can enroll outside of open enrollment. Insurers have said people are gaming the special enrollment periods—reserved for when people get married or move to a new residence, for instance—and the CMS has repeatedly asked for data to prove that gaming exists.

    Comments on the 2018 exchange proposals are due Oct. 6.

    Letter
    to the
    Editor

    Send us a letter

    Have an opinion about this story? Click here to submit a Letter to the Editor, and we may publish it in print.

    Recommended for You
    More than a dozen states to open vaccines to all adults
    More than a dozen states to open vaccines to all adults
    Becerra visits Nevada, stumps for pandemic aid and Obamacare
    Becerra visits Nevada, stumps for pandemic aid and Obamacare
    Sponsored Content
    Get Newsletters

    Sign up for enewsletters and alerts to receive breaking news and in-depth coverage of healthcare events and trends, as they happen, right to your inbox.

    Subscribe Today
    MH Magazine Cover

    MH magazine offers content that sheds light on healthcare leaders’ complex choices and touch points—from strategy, governance, leadership development and finance to operations, clinical care, and marketing.

    Subscribe
    Connect with Us
    • LinkedIn
    • Twitter
    • Facebook
    • RSS
    • Instagram

    Our Mission

    Modern Healthcare empowers industry leaders to succeed by providing unbiased reporting of the news, insights, analysis and data.

    MDHC_Logotype_white
    Contact Us

    (877) 812-1581

    Email us

     

    Resources
    • Contact Us
    • Advertise with Us
    • Ad Choices Ad Choices
    • Sitemap
    Editorial Dept
    • Submission Guidelines
    • Code of Ethics
    • Awards
    • About Us
    Legal
    • Terms and Conditions
    • Privacy Policy
    • Privacy Request
    Modern Healthcare
    Copyright © 1996-2021. Crain Communications, Inc. All Rights Reserved.
    • News
      • This Week's News
      • COVID-19
      • Providers
      • Insurance
      • Government
      • Finance
      • Technology
      • Safety & Quality
      • People
      • Regional News
        • Midwest
        • Northeast
        • South
        • West
      • Digital Edition
    • Insights
      • ACA 10 Years After
      • Best Practices
      • Special Reports
      • Innovations
    • Transformation
      • Patients
      • Operations
      • Care Delivery
      • Payment
    • Data/Lists
      • Rankings/Lists
      • Interactive Databases
      • Data Points
    • Op-Ed
      • Bold Moves
      • Breaking Bias
      • Commentaries
      • Letters
      • Vital Signs Blog
      • From the Editor
    • Awards
      • Award Programs
        • 100 Most Influential People
        • 50 Most Influential Clinical Executives
        • Best Places to Work in Healthcare
        • Health Care Hall of Fame
        • Healthcare Marketing Impact Awards
        • Top 25 Emerging Leaders
        • Top 25 Innovators
        • Minorities in Healthcare
          • - Luminaries
          • - Top 25 Minority Leaders
          • - Minorities to Watch
        • Women in Healthcare
          • - Luminaries
          • - Top 25 Women Leaders
          • - Women to Watch
      • Nominate
      • Previous Award Programs
        • Excellence in Nursing Awards
        • Design Awards
        • Top 25 COOs in Healthcare
      • Other Award Programs
        • 100 Top Hospitals
        • ACHE Awards
    • Events
      • Conferences
        • Women Leaders in Healthcare Conference
        • Social Determinants of Health Symposium
        • Healthcare Transformation Summit
        • Leadership Symposium
        • Virtual Briefings
          • - Hospital of the Future
          • - Mental Health
          • - Patient Safety & Quality
          • - Strategic Marketing
          • - Virtual Health
          • - Workplace of the Future
      • Galas
        • Best Places to Work Awards Gala
        • Health Care Hall of Fame Gala
        • Top 25 Minority Leaders Gala
        • Top 25 Women Leaders Gala
      • Webinars
      • COVID-19 Event Tracker
    • Listen
      • Podcast - Next Up
      • Podcast - Beyond the Byline
      • Sponsored Podcast - Healthcare Insider
      • Video Series - The Check Up
      • Sponsored Video Series - One on One
    • MORE +
      • Advertise
      • Media Kit
      • Newsletters
      • Jobs
      • People on the Move
      • Reprints & Licensing