Health insurers that sell plans on the federal HealthCare.gov marketplace may not face “enforcement remedies” in 2017 if they fail to follow all of the rules around consumer complaints, the CMS said in a recent memo.
The federal government expects many exchange insurers will experience a sizable uptick in enrollment next year following several mass exits from large carriers. Aetna, Humana and UnitedHealth Group each have significantly reduced their presence in the Affordable Care Act marketplaces. Each for-profit insurer argued their financial losses in the exchanges were too much to bear, although each company still sells plans in select markets.
Other insurers that stayed in the counties and states where the big insurers have departed likely will absorb the members who will lose their coverage. The CMS said that scenario “may present temporary operational challenges” that prevent exchange plans from meeting all federal standards, specifically those related to “consumer casework.”
Federal law requires health plans in the HealthCare.gov exchange to track instances where members complain about their coverage. These cases could include enrollment errors or improperly applying premium or cost-sharing subsidies. Insurers must submit casework to a centralized system and resolve the consumer complaints within 15 days. “Urgent cases” have to be handled within three days.
Health plans that experience “a substantial increase in enrollment” next year will not have to face CMS enforcement if they fall behind on that consumer casework, the federal government said. The CMS also will provide “technical assistance” to plans that are inundated with new members.
The safe harbor, however, will only be extended to plans that "make reasonable efforts to address concerns in an appropriate time frame," the CMS said in the memo.
Penalties related to casework were not outlined in 2017 guidance to exchange plans, although the CMS has the authority to impose fines or decertify plans that violate federal law.
The CMS did not make anyone available for further comment.
Open enrollment for 2017 exchange plans starts Nov. 1.
Update: The article has been clarified to note the safe harbor will extend to plans that "make reasonable efforts" with their consumer casework.
