WASHINGTON — The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule allowing for more consumers to use private brokers when signing up for health insurance under the Affordable Care Act (ACA), but some experts say the rule is not a big change from the current system.
“CMS previously implemented the successful enhanced direct enrollment (EDE) pathways, which allow web brokers and issuers to directly facilitate the purchase of Qualified Health Plans without re-routing consumers to HealthCare.gov,” the agency explained in a press release posted at around 6 pm ET last Wednesday, right before the Thanksgiving holiday. “These pathways improve the consumer experience in shopping for, applying for, and enrolling in Exchange coverage through approved private, third-party partner websites by allowing consumers to interact directly with these private partners and complete all steps in the eligibility and enrollment process on a single website.”
“Today’s rule proposes a new option for states to foster next-generation Exchanges,” the release continued. “Under these options, states would be able to implement a private partner-based design using DE [direct enrollment] and EDE as an alternative to their state’s enrollment websites. This design would leverage web brokers and issuers to serve as the consumer-facing means to apply and enroll in individual market QHPs [quality health plans] offered through the Exchange.”
Expanding on Georgia’s Waiver
The announcement is similar to a waiver that the agency recently granted to the state of Georgia, which is transitioning its enrollees off of Georgia’s federally mediated exchange and onto a private broker system.
Under the new model, announced in early November, “consumers will shop for, compare, and enroll in available plans through private sector partners, including web-brokers, health insurance companies, and traditional agents and brokers,” CMS said. “Increasing traffic to these private sector entities will not only incentivize these partners to increase their marketing and outreach to the uninsured, but will also drive improvements in the consumer shopping and enrollment experience.”
The idea of allowing states to set up these direct enrollment pathways is more of an incremental step than a major policy shift, according to Bob Laszewski, founder and president of Health Policy and Strategy Associates, a healthcare consulting firm in Alexandria, Virginia. That’s because “the state exchanges would still be in charge of broker standards and eligibility as well as consumer protections and other regulatory requirements,” he said in an email.
“The real question in my mind is just what will the Biden administration do with these proposals,” Laszewski continued. “My sense is that the Biden administration is going to be very aggressive in reversing a number of Trump era regulatory initiatives Democrats have long pointed to as undermining the health law.”
Possibility for Confusion
The effects of such a proposal really depend on exactly how each state sets things up, said Joel Ario, managing director at Manatt Health, a personal services firm based in New York City. “If I’m the consumer and I’m looking to find out what my options are, where do I go?” said Ario, who previously worked for President Obama as director of the Office of Health Insurance Exchanges at the Department of Health and Human Services.
“And if my answer is, I have to go to one of these private entities, either an insurer or web broker, and that’s my access point to the system, then that leads to disruption and consumer confusion, and it’s a difficult thing for the state to manage to make sure those interactions are all happening in a fair kind of way,” he said.
Consumers can use brokers now, but the exchange is still the ultimate place to actually be certified for coverage, which doesn’t appear to be true under the proposed rule, Ario continued. “In the model we currently have, that person can go to some of those places as a starting point, but they will still wind back to the exchanges in most cases to get eligibility determined and enroll in a program. And they can also go straight to the exchange and see all their options in a clear-cut way … I think the way I read the proposed regulation now, you may end up in a situation where you have to first go to one of these kinds of entities,” which will have their own back-office functions to determine eligibility, he said.
Tara Straw, JD, senior policy analyst at the Center on Budget and Policy Priorities, a left-leaning think tank here, said in an email that “the privatization of health insurance exchanges would invariably result in many people losing coverage since the transition to a disjointed system, versus the one-stop-shop of HealthCare.gov, would cause people to slip through the cracks. Consumers could be baffled by their broker and plan choices and hood-winked by brokers that push short-term plans and other skimpy coverage in lieu of the comprehensive insurance people are guaranteed to get on HealthCare.gov,” she said.
Under Georgia’s plan, for instance, “the web-brokers … are permitted to discriminate between carriers and fully display only the plans that pay a commission, with scant information about other plans — not even premiums and deductibles,” Straw said. “This means that consumers would need to visit multiple websites to understand all their options, which is confusing, overwhelming, and frustrating, and would undoubtedly lead some consumers to give up and others to make suboptimal choices.”
The Clock is Ticking
Asked about the timing of the proposed rule, which has a 30-day comment period, she said: “It’s clear that CMS knows the clock is ticking, so they rushed out the rule to try to finalize it before the end of the president’s term.”
Laszewski noted that the Trump administration may think of this proposal as a way to “declare victory” with the ACA on its way out of office — to argue that the administration’s market-oriented policies have driven health insurance prices down and allowed insurers to come back in. But that’s not really true, he said.
“After years of big rate increases that drove out people who got minimal subsidies or no subsidy during the Obama administration, the law stabilized pretty much by itself as just the most subsidized people were left, carriers had boosted rates so high they were profitable even though they had a very expensive risk pool, and the carriers ended up reaping big windfall profits as a result,” Laszewski added. “Those windfall profits brought carriers back in to serve the price-immune, highly subsidized remnant in the pool, while people making too much for a big subsidy or no subsidy at all abandoned their coverage.”
Source: MedicalNewsToday.com
