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  • Final Rule on ACA Insurance Exchanges Opens the Door for Market Instability, Disruptions in Care

    The US Department of Health and Human Services (HHS) is making good on the Trump administration's promise to relax requirements in the Affordable Care Act (ACA), releasing a set of rule changes—most opposed by APTA—that will alter the way states deal with "essential health benefits" (EHBs) and potentially reduce consumer access to help in choosing an insurance plan in the state marketplaces, among other provisions.

    HHS describes the final rule, issued on April 9, as "intended to advance the Administration's goals for increasing flexibility, improving affordability, strengthening program integrity, empowering consumers, promoting stability, and reducing unnecessary regulatory burdens associated with the [ACA]." APTA and many other health care and consumer organizations see things differently, and in comments mostly ignored by HHS when the proposed rule was released last year, warned that many of the changes will reduce care and disrupt markets.

    At the top of the list of changes opposed by APTA is the HHS decision to move ahead with a loosening of requirements around how states configure their "benchmark" plans—the minimum health insurance requirements for policies offered through a state's insurance exchange. Although HHS backed down from its original 2019 implementation date and made slight alterations from its proposed rule, the overall impact remains: beginning in 2020, states will be allowed to mix and match provisions in their benchmark plans, borrowing parts or entire plans from other states or otherwise selecting “a set of benefits to become its EHB-benchmark plan," primarily through adopting a private insurer's plan provisions that meet certain criteria.

    While the benchmark plans must contain the 10 EHBs required in the ACA (1 of which is rehabilitation and habilitation), the new rule allows states to significantly alter just how those EHBs are handled by adopting other, possibly less-generous, plan elements.

    "The final rule related to benchmark plans is only slightly better than the rule proposed in the fall of 2017, but HHS left some of the most potentially harmful provisions intact," said Kara Gainer, JD, APTA director of regulatory affairs. "Consumers will be left with a confusing, unsteady coverage system that could disrupt their care—practically the opposite scenario from the original intent of the ACA."

    Making matters worse, those disruptions in care could reoccur every year. The new rule also allows states to rearrange coverage provisions in benchmark plans annually. While APTA and other organizations contended that the change would create instability, the Centers for Medicare and Medicaid Services (CMS) argued that "because of the level of effort needed" to make a change, states probably won't attempt to mix things up every year. Plus, CMS added, if a state does decide to make an annual change, "there may be a specific reason…such as for a medical innovation."

    And maintaining consistent coverage through the insurance exchanges isn't the only thing that will become more difficult: it will also be harder for consumers to get help finding out what's available and signing up for a plan. Under the new rule, HHS will do away with certain requirements for "navigator" entities, the organizations that help consumers understand and choose an insurance plan through an exchange. Beginning this year, HHS will reduce the minimum number of navigator entities per exchange from 2 to 1, and will also lift a requirement that 1 navigator per exchange must be a community-focused nonprofit. Also eliminated: a mandate that the navigator entity be physically present in the exchange area it serves.

    APTA argued that "it is misguided for [CMS] to drastically reduce the level of assistance" provided to consumers, and pushed for even more navigator services. In its reply to comments, CMS cast the change as one that provides "increased flexibility."

    Other changes in the rule include giving more power to states to determine network adequacy—albeit with no direction on what constitutes an adequate network review process—and a loosening of requirements for Small Business Health Options Programs (SHOPs) to notify an employer of eligibility to purchase a qualified health plan (QHP) for their employees. Under the new rule, employers such as physical therapists in private practice would be left guessing about eligibility, and if they guessed wrong, purchased a QHP plan, and were later found ineligible, they would face a daunting and potentially costly appeals process. The rule also adds more options for exemptions from the individual mandate for health insurance—a mandate that lost its teeth in December 2017, when Congress approved a tax bill that eliminated the tax penalty for not having coverage.

    A full rundown of all the changes can be found on a fact sheet released by CMS.

    "These changes, all made under the guise of increased flexibility for states, amount to a weakening of the ACA through undermining the individual market and reducing health benefit protections," Gainer said. "APTA has long stated that there are many areas for improvement in the ACA and that we should be having discussions about needed changes. But these changes, no matter how they're characterized by CMS, are a move away from the real improvements consumers need."


    • Why the APTA ever supported and continues to support this boondoggle known as Obamacare (AKA “the affordable care act) is patently absurd. The administrators that “run” the APTA have obviously never been on the front lines of healthcare and I wonder if they have ever actually provided physical therapy while working in a practice where profits must be made. If they did, they would recognize there is nothing affordable about the “ACA”. You can’t keep you doctors or health care providers and your insurance premiums aren’t going down $2500.00 dollars. This will turn out to be the biggest scam perpetrated against the American people in the history of the United States. Even Obamacare’s architect, Jonathan Gruber openly stated that Americans would have to be stupid to support such a massive takeover of health care. This obviously was never about healthcare but instead putting government in charge of the largest wealth transfer from the haves to the have-nots in America’s history. My personal reimbursements have gone so low that I lose money on every Medicare patient I see and those reimbursements continue to decline . Many of my colleagues refuse to see Medicare patients even though I feel this is unethical. My businesses health insurance premiums are skyrocketing in June another 40%. We are going to be forced to lay off ultiple employees because we can’t generate enough revenue to pay salaries, and health insurance benefits. The ACA (I laugh everytime i here it called that) is ruining the quality of healthcare provided as clinicians are forced to see more patients in less time to make up for diminishing revenues. It’s also a flat out job killer. While the old system had many flaws, putting the federal government in charge of 1/6th of the nations economy was the absolute stupidest thing this country may have ever done. Why the APTA supported it and continues to support it may be the second.

      Posted by David on 4/12/2018 12:11 PM

    • When one takes the time to review the complete CMS rule and Fact sheet, you will find many positive changes. APTA should retain its role as an organization for its' members,not a political mouthpiece.

      Posted by Steven Huber -> =NR_E on 4/12/2018 2:52 PM

    • This is just another case of the APTA defending the status quo which is pathetic. The ACA has been nothing but a disaster, deductibles range from $6000-$10,000 for those who are not subsidized by us, the taxpayers. The act was nothing more than an attempt to crush private healthcare insurance to allow the government to go to single payor which was the ultimate goal. The APTA is once again taking political sides unfortunately not on the side of middle America.

      Posted by Brian on 4/12/2018 3:21 PM

    • Hooray for anything that corrects the disaster that is the ACA. As a 30 yr private practice owner who used to completely pay for my employees’ insurance premiums until the ACA made it impossible to do so, I am looking forward to these changes. The prior comments are all correct. Patients have $12,000-20,000 deductibles! California never even had a plan to make PT in-network, so ACA patients end up paying for PT in cash...which they cannot afford, so we take fees that are actually a loss, unless we over schedule. The APTA has been a disappointing, leftist, out-of-touch organization for my entire career. I have learned to ignore their political side.

      Posted by J on 4/14/2018 10:30 AM

    • I have seen nothing in this article that firmly demonstrates why the APTA should be opposed to these changes. In fact to me the changes seem like reasonable steps to fix big problems with the ACA. I certainly hope the APTA is not leaning toward becoming a partisan organization.

      Posted by Jason Koenigs on 4/16/2018 6:14 AM

    • The article demonstrates a good understanding of the situation. As states scramble to reduce cost to non mandated plans, essential benefits such as physical therapy could be cut from coverage further. Clients will be reduced to a few elite that can afford insurance and the struggling cash client that might not get effective treatment. When faced with a narrow window of enrollment periods and buyer beware products, 2019 will be a rough year for everyone using and making a living off healthcare.

      Posted by Matt McColm on 5/21/2018 1:38 PM

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