The Centers for Medicare and Medicaid Services (CMS) released its annual proposal to update Affordable Care Act (ACA) health plans, also known as “Obamacare” plans.
Most notably, CMS ignored patients’ demands to prevent payers, like Medicare or insurance companies, from using so-called “copay accumulator” programs to delay when a patient has met their cost sharing obligations. CMS said it would address the issue in a separate proposal.
When drug companies provide copay assistance to patients, CLL Society and other groups would like that assistance to count towards a patient’s cost sharing limit for the year. However, payers use accumulator programs to only count the patient’s share of the payment towards those annual limits. The courts have banned these programs, but CMS has yet to enforce this ban. It previously said it would propose how to implement a new ban in an upcoming proposal, but they have remained silent on the matter in their latest release. Payers have long claimed that enforcing the ban on accumulator programs will increase patients’ premiums, but patient groups see the practice as delaying the point at which patients’ deductibles have been met or satisfied for the year.
Other areas that are addressed in CMS’ annual updates to ACA plans include efforts to:
- Make enrolling in an ACA plan easier
- Reduce fraud
- Provide a grace period for paying premiums if and when those premiums increase beyond a certain threshold.
With respect to reducing fraud, CLL Society has been made aware of payers fraudulently enrolling people in plans they didn’t request or switching them from one plan to another. This, then, leaves patients to navigate the complicated paperwork to disenroll or switch back. CMS proposes, among other things, enforcement actions against agents that violate standards, and suspension of bad actors for violations.
CMS also proposed a three month “grace period” so that if patients are late paying their premiums, plans cannot immediately stop providing insurance. An additional proposal would allow plans to offer some sort of partial health coverage if patients can only afford to pay part of their premiums. It is unclear how this would work or why health plans would voluntarily provide less coverage at a lower premium. Finally, CMS wants greater oversight to ensure ACA plans provide an adequate number and geographic distribution of essential community providers.
