/ en Tue, 29 Apr 2025 23:20:36 -0500 Fri, 11 Apr 25 14:39:33 -0500 /news/headline/2025-04-11-aha-comments-cms-marketplace-integrity-and-affordability-proposed-rule <p>The AHA April 11 <a href="/lettercomment/2025-04-11-aha-comments-cms-marketplace-integrity-and-affordability-rule">commented</a> on the Centers for Medicare & Medicaid Services’ 2025 Marketplace Integrity and Affordability <a href="https://www.federalregister.gov/documents/2025/03/19/2025-04083/patient-protection-and-affordable-care-act-marketplace-integrity-and-affordability">proposed rule</a>. While the AHA expressed appreciation of the agency’s efforts to address concerns of large numbers of low-income individuals being unknowingly enrolled into Health Insurance Marketplace plans by certain brokers, the association expressed worry that some CMS proposals to address the issue could create barriers to care for eligible Marketplace consumers.  <br><br>The AHA said it was concerned with CMS estimates that 750,000 to 2 million consumers could lose their coverage due to the proposals. The association encouraged the agency to pause finalizing many of its proposals to give it and stakeholders additional time to consider the impacts while simultaneously taking action to stop brokers responsible for inappropriate enrollments. </p> Fri, 11 Apr 2025 14:39:33 -0500 Marketplace Issues/Stability /lettercomment/2025-04-11-aha-comments-cms-marketplace-integrity-and-affordability-rule <p>April 11, 2025</p><p>Mehmet Oz, M.D.<br>Administrator<br>Centers for Medicare & Medicaid Services<br>Hubert H. Humphrey Building<br>200 Independence Avenue, S.W., Room 445-G<br>Washington, DC 20201</p><p><em><strong>RE: Patient Protection and Affordable Care Act; Marketplace Integrity and Affordability (CMS-9884-P)</strong></em></p><p>Dear Administrator Oz:</p><p>On behalf of the ���������� Association’s (AHA) nearly 5,000 member hospitals, health systems and other health care organizations, including approximately 90 that offer health plans, and our clinician partners — including more than 270,000 affiliated physicians, 2 million nurses and other caregivers — and the 43,000 health care leaders who belong to our professional membership groups, we thank you for the opportunity to respond to the Centers for Medicare & Medicaid Services (CMS) rule on marketplace integrity and affordability.</p><p><strong>We appreciate CMS’ attention to concerns regarding the inappropriate enrollment of large numbers of low-income individuals into Health Insurance Marketplace coverage by certain brokers. </strong>As detailed in the proposed rule, it appears that in several states, some brokers have enrolled cohorts of low-income individuals (including, at times, Medicaid enrollees) into marketplace plans without the individuals’ knowledge. This has led to patient confusion, barriers to care and financial pressure on hospitals.</p><p>These impacts have been confirmed by AHA member hospitals. In these instances, hospitals scheduled services for patients when their coverage indicated Medicaid. In one example, the hospital only learned that the patient’s coverage had changed upon submitting the bills for care to the appropriate Medicaid agency, which then denied the claims due to the patient having marketplace coverage. The patients were completely unaware of this change in their coverage, and, unfortunately, in many instances, the hospital was not in-network with the marketplace plan, leaving the care uncovered. This change in coverage without the patients’ consent is interfering with patients' access to care, including services being postponed or canceled. One health system shared that they have found 2,500 unique patients with this issue, resulting in over $45 million in outstanding claims going unpaid as a result. A separate health care system estimates the financial impact on their hospitals is much greater.</p><p>The agency has proposed several policy changes to address this issue. While we appreciate the agency taking action to stop these inappropriate enrollments, we are concerned that the proposed changes will create barriers for truly eligible marketplace consumers without sufficient focus on the agents and brokers instigating these enrollments. <strong>Taken with other policies in the rule, CMS estimates that between 750,000 to 2 million consumers could lose their coverage.</strong> We are deeply concerned by these estimates of coverage loss, particularly as we have seen no credible evidence to support that such a high number of individuals have been impacted by inappropriate broker enrollments.</p><p><strong>Coverage loss of this magnitude would have substantial consequences for patient access to care, as well as the financial stability of hospitals, health systems, and other providers.</strong> As CMS notes in the rule, “some enrollees, particularly those facing financial constraints, might need to adjust their household budgeting to maintain coverage or, if they are not able to, become uninsured. Depending on the circumstances, these enrollees, if they become uninsured, could face higher costs for care and medical debt if care is needed. <em>These costs could in turn be incurred by hospitals and municipalities in the form of uncompensated care</em>” (emphasis added). These new costs to hospitals would come at a time when many hospitals and health systems, particularly critical access hospitals and those in rural areas, are operating with little to no margin. They cannot absorb further losses without consequences on access to care that will be felt by everyone in a community, not just those enrolled in marketplace coverage.<sup>1</sup></p><p><strong>For these reasons, we encourage the agency to pause finalizing many of these policies to give it and stakeholders additional time to consider the impacts while simultaneously investigating and taking appropriate action to stop the specific agents and brokers responsible for these inappropriate enrollments. In addition, we urge the agency to address reimbursement for services rendered to those impacted patients.</strong></p><p>Thank you for your consideration, and we look forward to working with the administration to ensure efficient and affordable marketplaces.<strong> </strong>Please contact me if you have questions, or feel free to have a member of your team contact Ariel Levin, AHA’s director of coverage policy, at 202-626-2335 or <a href="mailto:alevin@aha.org">alevin@aha.org</a>.</p><p>Sincerely,</p><p>/s/</p><p>Ashley Thompson<br>Senior Vice President<br>Public Policy Analysis and Development</p><div><hr><div id="ftn1"><p><sup>1</sup> <a href="/costsofcaring">/costsofcaring</a></p></div></div> Fri, 11 Apr 2025 12:10:58 -0500 Marketplace Issues/Stability /lettercomment/2025-03-27-aha-letter-opposing-physician-led-and-rural-access-quality-care-act-hr2191 <p>March 25, 2025</p><p>The Honorable Morgan Griffith<br>U.S. House of Representatives<br>2110 Rayburn House Office Building<br>Washington, DC 20515</p><p>Dear Representative Griffith:</p><p>On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, our clinician partners — including more than 270,000 affiliated physicians, 2 million nurses and other caregivers — and the 43,000 health care leaders who belong to our professional membership groups, the ���������� Association (AHA) writes to express our opposition to H.R. 2191, the Physician Led and Rural Access to Quality Care Act.</p><p>Rural hospitals are essential access points for care, economic anchors for their communities, and the backbone of our nation’s rural communities. These hospitals have maintained their commitment to ensuring local access to high-quality, affordable care despite continued financial and workforce challenges. The AHA strongly supports legislation that would enable rural hospitals across the nation to better care for their communities. However, we believe that H.R. 2191 is misguided legislation that would skew the health care marketplace in favor of physicians who self-refer patients to hospitals they own and would destabilize rural health care while failing to improve access to quality care.</p><p>H.R. 2191 would result in additional gaming of the Medicare program, jeopardize patient access to emergency care, potentially harm sicker and lower-income patients, and severely damage the ability of 24/7 full-service community hospitals to provide care in rural areas.</p><p>Physician self-referral — whether in rural, suburban or urban communities — is the antithesis of fair competition. The problematic practice allows physicians to steer their most profitable cases to facilities they own — facilities that often call 9-1-1 to handle their emergencies and are often located in the most affluent areas. By performing the highest-paying procedures for the best-insured patients, physician-owners inflate health care costs and drain essential resources from community hospitals, which depend on a balance of services and patients to provide indispensable treatment, such as behavioral health and trauma care. By increasing the presence of these self-referral arrangements, H.R. 2191 would only further destabilize community care.</p><p>Since the Medicare Modernization Act of 2003, Congress has supported ending the egregious and costly practice of physician self-referral to hospitals they own. Current law represents a 15-year compromise that (1) allows existing physician-owned hospitals (POHs) to continue to treat Medicare patients, (2) permits the expansion of those physician-owned hospitals that meet communities’ needs for additional hospital capacity and treat low-income patients, and (3) prohibits Medicare from covering services in any new physician-owned hospitals established after Dec. 31, 2010. Congress established these guardrails to protect the Medicare program from overutilization, patient steering and the harmful patient selection practices that POHs employ.</p><p>Data have shown time and time again that POHs select only the healthiest and most profitable patients, serving lower proportions of Medicaid, dual eligible and uncompensated care than full-service acute care hospitals. The <a href="https://www.cbo.gov/sites/default/files/111th-congress-2009-2010/costestimate/amendreconprop.pdf" target="_blank" title="Congressional Budget Office Website">Congressional Budget Office</a>, the <a href="https://www.medpac.gov/wp-content/uploads/import_data/scrape_files/docs/default-source/reports/Mar05_SpecHospitals.pdf" target="_blank" title="Medicare Payment Advisory Commission">Medicare Payment Advisory Commission</a> and the <a href="https://public-inspection.federalregister.gov/2023-16252.pdf" target="_blank" title="Center for Medicare & Medicaid Services">Centers for Medicare & Medicaid Services</a> all have concluded that physician self-referral leads to greater per capita utilization of services and higher costs for the Medicare program, among other negative impacts.</p><p>For these reasons, the AHA strongly opposes the expansion of POHs — by either creating new categories of exceptions or allowing existing POHs to expand — and cannot support H.R. 2191. Congress should maintain current law, preserve the ban on physician self-referrals to new physician-owned hospitals, and retain restrictions on the growth of existing physician-owned hospitals, regardless of location.</p><p>Sincerely,</p><p>/s/</p><p>Lisa Kidder Hrobsky<br>Senior Vice President, Advocacy and Political Affairs</p> Thu, 27 Mar 2025 10:36:14 -0500 Marketplace Issues/Stability <div class="container"><div class="row"><div class="col-md-8"><p>The Centers for Medicare & Medicaid Services (CMS) March 10 <a href="https://www.cms.gov/files/document/MarketplacePIRule2025.pdf" target="_blank" title="CMS: Patient Protection and Affordable Care Act; Marketplace Integrity and Affordability">released new proposed policies</a> for health insurance marketplaces, including the issuers, agents and brokers who assist marketplace enrollees. If finalized, the rule would shorten the open enrollment period for all marketplaces to Nov. 1-Dec. 15 and address issues with brokers fraudulently enrolling individuals without their consent by ending a special enrollment period (SEP) for low-income individuals. CMS also proposes a change to the premium adjustment percentage that would increase the maximum annual cost sharing limitation. The proposed rule includes updates to the income verification process and pre-enrollment verification process for SEPs, changes to the essential health benefits, and modifications to the redetermination and re-enrollment processes, among other policies. Many of the proposed policies would reinstate policies previously finalized during the prior Trump administration.</p><h2>Major Provisions</h2><h3>Open Enrollment</h3><p>CMS proposes to shorten the open enrollment period to Nov. 1-Dec. 15 for all individual market coverage, on and off the marketplaces and including those marketplaces operated by individual states, beginning in 2025 for the 2026 coverage year. Currently, open enrollment periods for federally facilitated marketplaces run from Nov. 1-Jan. 15; state-based marketplaces (SBM) have flexibility to extend open enrollment beyond that window.</p><h3>Low-income Monthly SEP</h3><p>CMS proposes to end the monthly SEP for those with projected household incomes at or below 150% of the federal poverty level (FPL). This proposal is expected to help curtail ongoing broker fraud in which brokers enroll individuals in marketplace plans without their knowledge or authorization.</p><h3>Agent, Broker and Web-broker Termination</h3><p>CMS proposes to improve transparency of agent, broker and web-broker compliance review by adopting a “preponderance of the evidence" standard. CMS expects this to reduce noncompliant behavior, including improper and unauthorized enrollment.</p><h3>Premium Adjustment Percentage Methodology</h3><p>CMS proposes to revert to the premium adjustment percentage methodology finalized in the 2020 Notice of Benefit and Payment Parameter, which uses private health insurance premiums to estimate the future premium growth. This calculation is used to determine cost-sharing parameters, such as the maximum annual limitation on cost sharing.</p><p>Based on the proposed methodology, CMS proposes a maximum annual limitation on cost sharing for plan year 2026 of $10,600 for self-only coverage and $21,200 for family coverage. These amounts are roughly 15 percent higher than the plan year 2025 cost-sharing limits.</p><h3>Eligibility Verification for SEP</h3><p>CMS proposes to require pre-enrollment eligibility verification for all types of SEPs across all marketplaces, including SBMs. Currently, pre-enrollment verification is limited to the loss of minimum essential coverage SEP. In addition, CMS proposes to require all marketplaces to conduct pre-enrollment eligibility verification for at least 75 percent of all new enrollees.</p><h3>De Minimis Thresholds</h3><p>CMS proposes to widen the de minimis ranges for most individual and small group market plans subject to the actuarial value requirements to +2/-4 percentage points. For expanded bronze plans, CMS proposes a new de minimis range of +5/-4 percentage points. CMS also proposes to remove the de minimis range requirements of +2/0 percentage points for individual market silver plans, as well as the +1/-1 percentage point de minimis range for silver cost-sharing reduction plans.</p><h3>Deferred Action for Childhood Arrivals (DACA) Recipients</h3><p>CMS proposes to change the definition of “lawfully present” so that DACA recipients would no longer be eligible to enroll in marketplace or basic health plans or receive premium tax credits or cost-sharing reductions. DACA recipients recently gained eligibility through the 2024 DACA Rule.</p><h3>Essential Health Benefits</h3><p>CMS proposes prohibiting classifying gender-affirming care as an essential health benefit beginning in plan year 2026. Plans could cover gender-affirming care if they choose to.</p><h3>Program Integrity</h3><p>CMS proposes several policies intended to ensure that individuals are only enrolling in plans and receiving premium tax credits that they are eligible to receive, including:</p><ul><li>Requiring all enrollees who attest to projected household income between 100-400% FPL but whose income verification results in a household income below 100% FPL to answer additional verification questions and provide supporting documentation. This policy is intended to ensure only eligible individuals above 100% FPL receive premium tax credits. This policy was finalized in the 2019 Notice of Benefit and Payment Parameters but was vacated by the courts.</li><li>Reinstating a policy deeming an individual ineligible for future premium tax credits if they fail to file their federal income tax and reconcile premium tax credits for one year. This policy was changed to two consecutive tax years in the 2024 Notice of Benefit and Payment Parameters.</li><li>Requiring marketplaces to verify income with other trusted data sources if IRS data is not available, including requiring additional supporting documentation or other actions by enrollees. Currently, marketplaces must accept enrollees’ self-attestation of projected household income if IRS income verification is not possible.</li><li>Removing the 60-day extension of the statutorily required 90-day window during which enrollees must resolve income inconsistencies.</li></ul><h3>Additional Policies</h3><p>CMS proposes several additional policies, including:</p><ul><li>Allowing issuers to require that enrollees pay past-due premiums before enrolling in new coverage.</li><li>Eliminating the fixed-dollar and gross percentage-based premium thresholds finalized in the 2026 Notice of Benefit and Payment Parameters and requiring issuers to adopt a net percentage-based threshold, which would require enrollees to pay more of their premium to maintain coverage.</li><li>Changing the eligibility redetermination process for enrollees in zero-dollar premium plans to require enrollees to affirm or update their eligibility information or face $5 premiums upon re-enrollment. The premiums would be eliminated once the enrollee confirmed their eligibility.</li><li>Remove the re-enrollment hierarchy that allows marketplaces to re-enroll low-income bronze plan enrollees into a silver plan, if the silver plan is the same product, has the same provider network and has an equal or lower premium.</li></ul><h3>Coverage Impacts</h3><p>CMS estimates that between 750,000 and 2 million individuals would lose marketplace coverage in 2026 as a result of the policies proposed in this rule. Some of that coverage loss would be due to improper and unauthorized enrollment by agents and brokers, while other losses would be due to the increased administrative burden associated with complying with the new requirements.</p><h2>Further Questions</h2><p>Comments on the proposed rule are due 30 days following publication in the Federal Register. For more information, contact Ariel Levin, AHA’s director of coverage policy, at <a href="mailto:alevin@aha.org?subject=RE: Regulatory Advisory: CMS Issues 2025 Marketplace Integrity and Affordability Proposed Rule">alevin@aha.org</a>.</p></div><div class="col-md-4"><a href="/system/files/media/file/2025/03/Regulatory-Advisory-CMS-Issues-2025-Marketplace-Integrity-and-Affordability-Proposed-Rule.pdf"><img src="/sites/default/files/inline-images/Page-1-Regulatory-Advisory-CMS-Issues-2025-Marketplace-Integrity-and-Affordability-Proposed-Rule.png" data-entity-uuid="cd05876f-3ced-4647-9ea0-5a72630acf19" data-entity-type="file" alt="Regulatory Advisory: CMS Issues 2025 Marketplace Integrity and Affordability Proposed Rule page 1." width="695" height="900"></a></div></div></div> Tue, 11 Mar 2025 16:39:48 -0500 Marketplace Issues/Stability <div class="container"><div class="row"><div class="col-md-8"><p>In December, Congress passed a legislative package to fund the government through March 14 and extend key health care provisions through the end of March. Congressional action is needed once again to fund the government and ensure long-term stability for these critical health care programs. At the same time, House and Senate Republicans are planning a strategy to use the budget reconciliation process to accomplish some of their legislative priorities, and Congress must raise the debt ceiling in the coming months. As part of these strategies, they are considering proposals that would reduce funding for hospital care, including reductions to the Medicaid program, jeopardizing access to the 24/7 care and services that hospitals provide.</p><h2>Action Needed</h2><p><strong>Please ask your senators and representatives to prevent Medicaid disproportionate share hospital payment cuts from taking effect; extend enhanced low-volume adjustment and Medicare-dependent hospital programs that expand access to care in rural areas; and extend telehealth and hospital-at-home waivers. These policies are currently set to expire at the end of March and must be extended.</strong></p><p><strong>In your discussions with your legislators, please continue to share the valuable role your hospital or health system plays in the community they represent and urge them to reject cuts that would jeopardize access to hospital care and services that patients rely on.</strong></p><p>More details and resources to support your advocacy efforts on these important issues follow.</p><h2>Health Care Extenders</h2><p>Congress passed a legislative package in December that extended some key health care provisions through the end of March, but additional congressional action is needed.</p><ul><li><strong>Prevent Medicaid DSH Cuts.</strong> The Medicaid disproportionate share hospital (DSH) program provides essential financial assistance to hospitals that care for our nation’s most vulnerable populations — children, the impoverished, disabled and elderly. Without congressional action, billions in cuts would take effect April 1. <strong>See the </strong><a href="/system/files/media/file/2020/02/fact-sheet-medicaid-dsh-0120.pdf"><strong>Medicaid DSH fact sheet</strong></a><strong> for more details.</strong></li><li><strong>Extend Key Rural Programs.</strong> The enhanced low-volume adjustment and Medicare-dependent hospital programs provide rural, geographically isolated and low-volume hospitals additional financial support to ensure rural residents have access to care. Without congressional action, these programs will expire on April 1. <strong>See the </strong><a href="/fact-sheets/2022-08-30-fact-sheet-rural-hospital-support-act-s4009-assistance-rural-community"><strong>rural programs fact sheet</strong></a><strong> for more details.</strong></li><li><strong>Extend Telehealth and Hospital-at-Home Waivers.</strong> Congress has extended telehealth waivers and the hospital-at-home program through March 31, but additional action is needed. See the <a href="/advocacy/advocacy-issues/2024-10-31-advocacy-issue-telehealth-waivers">telehealth</a> and <a href="/fact-sheets/2024-08-06-fact-sheet-extending-hospital-home-program">hospital-at-home fact sheets</a> for more details.</li></ul><h2>Critical Issues for the 119th Congress</h2><p>Following our Feb. 5 advocacy update webinar for members, we are providing new fact sheets and primers on emerging issues of significant importance for hospitals and health systems. We will be providing updates, new resources and data on these and other issues to help your advocacy efforts throughout the year.</p><h3>Reject Cuts to Medicaid</h3><p>Republican leaders continue to have discussions about how to use reconciliation — a <a href="/issue-landing-page/2025-02-07-budget-reconciliation-process-resource-page">budget tool</a> that gives Congress a fast-track mechanism to avoid the Senate filibuster and pass legislation with a simple majority. House and Senate Republicans are expected to use the budget reconciliation process to try to pass key agenda items on taxes, energy and border security, and they may look to health program funding as a way to pay for this legislation. <strong>Such proposals could significantly reduce federal spending for the Medicaid program. Even a small portion of possible reductions could have wide-ranging negative consequences for the health and well-being of both Medicaid enrollees and the broader health care system.</strong></p><p>The AHA has developed a number of resources hospitals and health systems can use as part of their advocacy efforts, including the following:</p><ul><li><a href="/fact-sheets/2025-02-07-fact-sheet-medicaid">General Fact Sheet on Medicaid</a></li><li><a href="/fact-sheets/2025-02-07-fact-sheet-medicaid-provider-taxes">Fact Sheet on Medicaid Provider Taxes</a></li><li><a href="/fact-sheets/2025-02-07-fact-sheet-medicaid-hospital-payment-basics">Fact Sheet on Medicaid Hospital Payment Basics</a></li><li><a href="/fact-sheets/2025-02-07-fact-sheet-capita-caps-medicaid-program">Medicaid Per Capita Caps</a></li></ul><h3>Extend Enhanced Premium Tax Credits</h3><p>The federal government offers enhanced premium tax credits (EPTCs) to help eligible individuals and families purchase coverage on the health insurance marketplaces. These policies are scheduled to expire at the end of 2025. <strong>Congress should extend the EPTCs before the end of the year</strong> as they have increased access to health care coverage and high-quality care for patients and communities served by hospitals, health systems and other providers. <strong>Download the AHA fact sheet, which includes new data on the negative impact of not extending the </strong><a href="/fact-sheets/2025-02-07-fact-sheet-enhanced-premium-tax-credits"><strong>EPTCs</strong></a><strong>.</strong></p><h3>Reject Site-neutral Payment Cuts</h3><p>Congress is considering several bills that would impose billions in Medicare site-neutral payment reductions for services provided in hospital outpatient departments. <strong>Congress should reject site-neutral proposals</strong> because they would reduce patient access to vital health care services, particularly in rural and other medically underserved communities. <strong>See AHA resources on the detrimental impact of </strong><a href="/advocacy/advocacy-issues/2023-09-11-advocacy-issue-site-neutral-payment-proposals"><strong>site-neutral policies</strong></a><strong>.</strong></p><h3>Protect the 340B Drug Pricing Program</h3><p>For more than 30 years, the 340B Drug Pricing Program has provided financial help to hospitals serving vulnerable communities to manage rising prescription drug costs. However, some in Congress and the pharmaceutical industry want to see the program scaled back. <strong>Congress should protect the 340B program</strong> for all providers and ensure the program continues to help stretch limited resources and provide more comprehensive services to more patients. <strong>Download the AHA fact sheets on the </strong><a href="/340b-drug-savings-program"><strong>340B program</strong></a><strong>.</strong></p><h2>Further Questions</h2><p>Visit the <a href="/advocacy/action-center">AHA Action Center</a> for more resources on these issues and other priorities important to hospitals and health systems. Watch for more Action Alerts and resources from the AHA to assist your advocacy efforts. If you have further questions, please contact AHA at 800-424-4301.</p></div><div class="col-md-4"><p><a href="/system/files/media/file/2025/02/Contact-Your-Lawmakers-and-Urge-Them-to-Extend-Key-Health-Care-Policies-Set-to-Expire-Next-Month.pdf" target="_blank" title="Click here to download the Action Alert ACTION NEEDED: Contact Your Lawmakers and Urge Them to Extend Key Health Care Policies Set to Expire Next Month PDF."><img src="/sites/default/files/inline-images/Page-1-Contact-Your-Lawmakers-and-Urge-Them-to-Extend-Key-Health-Care-Policies-Set-to-Expire-Next-Month.png" data-entity-uuid="2dd3d759-0b56-4a54-8cdb-d635ee169360" data-entity-type="file" alt="Action Alert: ACTION NEEDED: Contact Your Lawmakers and Urge Them to Extend Key Health Care Policies Set to Expire Next Month page 1." width="696" height="900"></a></p></div></div></div> Fri, 07 Feb 2025 15:04:02 -0600 Marketplace Issues/Stability /advancing-health-podcast/2025-01-27-leadership-dialogue-series-tackling-todays-health-care-challenges <p>2025 will bring new and familiar challenges for the health care industry, and the ���������� Association is ready to support hospitals and health systems across the nation. In the first Leadership Dialogue of 2025, Tina Freese Decker, president and CEO of Corewell Health and 2025 AHA board chair, talks with two policy experts at the AHA — Stacey Hughes, executive vice president of government relations and public policy, and Ashley Thompson, senior vice president of public policy analysis and development — about the current political climate, the potential impacts to health care policies, and how the AHA is primed to continue its mission to advance health in America.</p><hr><div></div><hr><div class="raw-html-embed"> <details class="transcript"> <summary> <h2 title="Click here to open/close the transcript."> <span>View Transcript</span><br>   </h2> </summary> <p> 00:00:00:20 - 00:00:29:13<br> Tom Haederle<br> Welcome to Advancing Health - and to the first Leadership Dialogue of the year - hosted by the ���������� Association's 2025 Board Chair, Tina Freese Decker, president and CEO of Corewell Health. Today, two senior AHA leaders join Tina to discuss key issues in health care and how the AHA is working on many fronts to support hospitals and health systems so they can provide the best care to patients and communities. </p> <p> 00:00:29:15 - 00:00:56:10<br> Tina Freese Decker<br> Hello and thank you everyone for joining us today. In 2025, the ���������� Association is all in in tackling the challenges that are facing health care today. I am looking forward to using this Leadership Dialogue series to highlight the incredible ways the ���������� Association and our member hospitals and health systems are making health better. My name is Tina Freese Decker, and I'm the president and CEO of Corewell Health </p> <p> 00:00:56:12 - 00:01:23:05<br> Tina Freese Decker<br> and the 2025 ���������� Association board chair. As we kick off this new year, I want to start by introducing you to a few amazing leaders within the ���������� Association who will help us navigate the year ahead. The ���������� Association is here to help remove those barriers so as hospitals and health systems, we can provide the very best care to our patients and communities. </p> <p> 00:01:23:07 - 00:01:45:04<br> Tina Freese Decker<br> So today, while we don't have all the time to meet the full AHA team, I'm so excited to introduce you to Stacy Hughes and Ashley Thompson, two fantastic individuals who lead the AHA's government relations and public policy work. One of the things that gives me the most confidence in our approach is when I listen and I talk with them. </p> <p> 00:01:45:07 - 00:02:02:23<br> Tina Freese Decker<br> So I thought it would be really beneficial for all of you, our members, to hear from them. So let's begin. So Stacy and Ashley, welcome. So glad to see you today. Let's start with some introductions and share what you do with the ���������� Association. Stacy? </p> <p> 00:02:02:25 - 00:02:21:05<br> Stacey Hughes<br> Sure. Thank you for this opportunity. We're so excited about your year ahead and working with you. And we're really appreciative of having a chance to showcase a little bit about what our team is up to. But I'm Stacy Hughes. I'm executive vice president in the D.C. office and oversee regulatory policy, federal relations PAC, and some of our communication efforts. </p> <p> 00:02:21:08 - 00:02:25:06<br> Stacey Hughes<br> Have a great team here. And we're going to talk more about that. But that's my role here, Tina. </p> <p> 00:02:25:14 - 00:02:26:28<br> Tina Freese Decker<br> Thank you. Ashley? </p> <p> 00:02:27:00 - 00:02:50:00<br> Ashley Thompson<br> Thank you, Tina, so much for giving us this opportunity and for your leadership on the board in the past and especially this year as chair. I'm Ashley Thompson. I'm the senior vice president of policy here at AHA. I lead a team of about 24 very amazing, talented individuals. The work that we do is really on behalf of hospitals and the patients they serve. </p> <p> 00:02:50:03 - 00:03:10:11<br> Tina Freese Decker<br> As we think about the work ahead of us this year, I also want to learn more about what you and your teams are doing. So the ���������� Association is a bipartisan organization, and we work with all lawmakers to advance the issues that mean the most to us as hospitals and health systems. So, Stacy, tell us about the team that you lead. </p> <p> 00:03:10:14 - 00:03:17:10<br> Tina Freese Decker<br> The depth of expertise and their balance and how your team is preparing for this new administration in Congress. </p> <p> 00:03:17:12 - 00:03:36:03<br> Stacey Hughes<br> Sure. And I couldn't be more proud to be honest with you. And I have to say, you know, I give Rick and others a such a shout out for the legacy, you know, Ashley says she's here 23 years, I'm starting year five. Boy, both what I inherited as a team that were here day one, and then how we've grown as people have, you know, rolled off or changed jobs. </p> <p> 00:03:36:05 - 00:04:01:12<br> Stacey Hughes<br> It is solid. We've got, you know, lobbyists that have all worked largely on Capitol Hill or they were deeply, deeply immersed in the issues that are critical to hospitals. I'll ask you to talk about the policy team that we work on together. We've got such currency politically with the lobbyists that are on the team. Our colleagues and my colleagues, Lisa Kidder, she's been here 20 years. Amy Kuhlman, there's no one better than Amy in terms of leading our lobbyist team. </p> <p> 00:04:01:12 - 00:04:24:17<br> Stacey Hughes<br> So both their experience actually on the Hill, writing bills, knowing all the member offices. You know, we cover every single office here, you know, House and Senate. That's a lot to say Grace over. In terms of preparing, obviously this is a unified town now, it's a Republican town. We had a bit of a sweep. So we're busy getting ready to look at how we frame our issues with a very specific audience. </p> <p> 00:04:24:19 - 00:04:44:10<br> Stacey Hughes<br> But in addition, Tina, as you know, this is a pretty sweeping election in terms of retirements. There are 14 new Senate freshmen between Republicans and Democrats. There are about 55 new freshmen House members. So a big part of what we're doing is educating them early and often. Lisa and Amy and others are putting together a 101 of hospital issues. </p> <p> 00:04:44:16 - 00:05:00:09<br> Stacey Hughes<br> They understand our field immediately and early, and be a resource for them. So everyone is readying for what is going to be. And then we'll talk more about what the year ahead, what the expectations are. But it's a lot. And we are excited that the team is ready, but they have great skills. </p> <p> 00:05:00:09 - 00:05:04:20<br> Stacey Hughes<br> And, couldn't be more proud to be collaborating with them and leading them. </p> <p> 00:05:04:23 - 00:05:14:25<br> Tina Freese Decker<br> And as you do that education, are our lawmakers interested in health care? Are they appreciative of the education, the orientation and the one on one that we provide? And when we show up. </p> <p> 00:05:14:28 - 00:05:31:24<br> Stacey Hughes<br> They are and, you know, we're in the process of so getting out some of our very specific every congressional districts or what that hospital footprint looks like, you know, who's in your backyard, how many jobs are you providing that community? What is your role in the economic engine of that community? What are you doing in terms of serving that population? </p> <p> 00:05:31:24 - 00:05:48:28<br> Stacey Hughes<br> And they are interested. I think that, you know, as you know, there are a lot of threats around the financing of hospital, particularly the burden on the federal government and debt. And so being able to bring it to life to them, what we're really doing with limited resources and our contribution to communities, </p> <p> 00:05:48:28 - 00:06:03:25<br> Stacey Hughes<br> they do appreciate it. And particularly the role we play in terms of our jobs and their district. But it takes time. You know, you really have to tell the story, go to make sure you invest in that time. You always want to know your members before you need them. And I think that's important. </p> <p> 00:06:03:27 - 00:06:16:00<br> Tina Freese Decker<br> Ashley, I'd like to ask you the same question. So share a quick overview with us of some of the issue areas of policy expertise that you have amongst your team members, and what's the one thing your team is gearing up for this year that you can share with us? </p> <p> 00:06:16:02 - 00:06:42:09<br> Ashley Thompson<br> Well, like Stacey, I am so proud of the policy team. Many of the individuals, I think there are 24 of them, have been here for a very long time. They are true issue area experts. They are smart, they are talented, they are motivated. And I will say that they really want to improve health and health care in America and get hospitals, the resources that they need to really care for their patients. </p> <p> 00:06:42:11 - 00:07:09:03<br> Ashley Thompson<br> We are kind of divided into four areas. So we have Medicare payment, coverage, quality and patient safety, and data and research are kind of the big buckets. But underneath them we tackle probably any issue that hospitals deal with. We have experts on AI, we have experts on prior authorization. We have experts on quality. So it's really a diverse group. </p> <p> 00:07:09:06 - 00:07:27:09<br> Ashley Thompson<br> I would say that it's really hard to pick the one issue that they're going to be dealing with this year. I think that there's probably four that are most important. And Stacey and I have been working on this together with others across the association. I think one of them is to protect Medicaid and its enrollees. </p> <p> 00:07:27:09 - 00:07:49:16<br> Ashley Thompson<br> I think the second one is to ensure what we call the marketplace premium tax credits continue after the end of this year. About 10 million people have gotten coverage due to those tax credits, and we don't want them to lose coverage. The third area is to make sure that hospitals are not subjected to site neutral payments. </p> <p> 00:07:49:18 - 00:08:09:12<br> Ashley Thompson<br> And then I'd say the fourth area is probably protecting 340B, which is the drug pricing program. So those are definitely on our radar. But it goes beyond that. There are so many issues, I think our advocacy agenda came out this week. I haven't counted there's probably 75 plus issues that we are actively working. </p> <p> 00:08:09:14 - 00:08:34:21<br> Tina Freese Decker<br> And we're so appreciative of kind of highlighting the main areas that we need to focus on, but then understanding that as hospitals and health systems, we're not all alike and there are different issues that come up that we need to navigate as we move forward. Again, what I am so proud of is your team, both of your teams, really have the expertise and the experience to help tackle this and guide us as members as we move forward. </p> <p> 00:08:34:23 - 00:08:56:08<br> Tina Freese Decker<br> You know, there's also a much broader team at ���������� Association that's supporting the work of our field  - from legal to communications to the quality of patient safety, field engagement. There's so many people that are ready to assist our members. So let's talk a bit about how our members and our leaders and our hospitals and our health systems might work with the ���������� Association on those issues. </p> <p> 00:08:56:11 - 00:09:13:02<br> Tina Freese Decker<br> So, Stacy, can you tell us how your team engages with the members? And this time not the members of the Capitol Hill, but it's like hospitals and health systems. How can our hospital and health system leaders get more involved in advocacy efforts, and why is that important? </p> <p> 00:09:13:05 - 00:09:31:26<br> Stacey Hughes<br> Sure. Well, first and foremost, you know, our teams are constantly working with our members. I know Ashley would say the same, whether it's policy or federal relations. And that's just in the everyday, just grind of learning how to address issues and learn from them in terms of what we actually advocate for, that's an ongoing thing. But to your point, there are a lot of different ways that we work with members. </p> <p> 00:09:31:26 - 00:09:51:09<br> Stacey Hughes<br> One is through our government relations officer network. Certainly we work through our allieds, all the 50 state hospital executives, and is a huge partner for us in terms of our advocacy. But in terms of your of a hospital health system, main thing you can do is get to know your delegation. You know, I know you guys do this both obviously with your state, representatives and your state elected officials. </p> <p> 00:09:51:09 - 00:10:07:20<br> Stacey Hughes<br> But on the federal side, really getting to know them and telling that story often. And also, don't be afraid to go to them and let them know when you have a problem. You really want to get them invested in your success. And it doesn't take much. And I think we all, going through Covid, we saw how much everyone does stand up. </p> <p> 00:10:07:20 - 00:10:25:00<br> Stacey Hughes<br> They recognize the importance of making sure we have a sustainable, functioning hospital network and health systems. And so being sure to take that leap, give your member a call, get to know the staff and being willing to advocate. I mean, I will say, you know, we put out these advocacy alerts and, we try to be judicious. </p> <p> 00:10:25:00 - 00:10:45:00<br> Stacey Hughes<br> We don't want to say "hair on fire" every day, but we do have a lot of challenges coming, Tina, as you know, in terms of all the pressures to address some of the deficit issues, mandatory programs like Medicare, Medicaid are the top drivers of the deficit and spending. So we have a lot coming up. But we really say when we do give a call to action, we really need it. </p> <p> 00:10:45:00 - 00:11:00:21<br> Stacey Hughes<br> And in particular, if you know you have a member of Congress or senator that is uniquely positioned on committees of jurisdiction as well as leadership, you want to make sure there no daylight between what you're doing, what your needs are, and what they understand in terms of their education. </p> <p> 00:11:00:24 - 00:11:11:25<br> Tina Freese Decker<br> Great advice. Thank you so much, Ashley. Similarly, are there examples of member engagement that you can speak to that have been particularly successful or impactful in influencing policy development? </p> <p> 00:11:11:28 - 00:11:38:24<br> Ashley Thompson<br> Yeah, I actually think that one of the reasons why AHA is so successful is because of our policy development process. I think it's very unique. Through our committees and our regional policy board meetings, we touch probably 550 CEOs or C-suite leaders three times a year. And we bring to them, you know, our committees, our grouped by kind of type of hospital, whether you're rural or post-acute or whether you're behavioral health. </p> <p> 00:11:38:26 - 00:12:02:26<br> Ashley Thompson<br> And then our regions are just what it says. We divide up by region and they weigh in on policy development. So they weigh in on what should we do about physician payment, what should we do about health care affordability? What should we do about the increase in medical debt? What should we do about X, Y, and Z? And it's a really a thoughtful, like iterative process. </p> <p> 00:12:02:29 - 00:12:39:24<br> Ashley Thompson<br> We also have strategic leadership groups. We also have task forces that we staff on certain issues, whether it's principles or whether it's health care, the future. You know, what should we do about workforce issues? So we really rely on everyone to weigh in. And of course, our board of trustees. So we rely very heavily on our board. And thank you again for your chairmanship of it to help direct the association, to direct our policy positions, to direct what recommendations we come up with, and often to direct our strategy of how to achieve what we want in terms of outcomes. </p> <p> 00:12:39:24 - 00:12:59:11<br> Ashley Thompson<br> And so I do think that AHA, and particularly probably the policy team given the work that we do, has a lot of connections and we really rely on that and we want to hear from our members and we want them to be active and engaged, because the more they communicate with us, the better we can represent them on Capitol Hill or with the administration. </p> <p> 00:12:59:13 - 00:13:28:16<br> Tina Freese Decker<br> I completely agree, and one of the most impactful, stories that I have is when I took one of our lawmakers through our mental health area and just highlighted what we are doing well, but what we need their support in. And then you could see that happen with bills came up and things needed to be impacted. And so I'm sure that there are stories like that in every part of our organizations and our membership about how that personal touch is so incredibly important as we drive forward. </p> <p> 00:13:28:16 - 00:13:37:27<br> Tina Freese Decker<br> All right. Are there any last comments, or thoughts on the year ahead that would be most helpful for you and your teams that you want to share with us? </p> <p> 00:13:38:00 - 00:14:02:21<br> Ashley Thompson<br> I think it's going to be a very challenging year. I know that the AHA is going to be really working hard on behalf of our members, and I think that the team at is very motivated to do so. Very similar to employees in hospitals, or the staff in the hospitals. I think that we tend to rise when there's a crisis and we rise to that occasion. </p> <p> 00:14:02:21 - 00:14:24:08<br> Ashley Thompson<br> And whether it's Covid or whether it was going to be repeal and replace of the ACA a few years ago, several years ago, or whether it's the Change Health care cyber event, I really think that AHA is here to serve its members, to get them through those hard times and to put them on a trajectory in the future. </p> <p> 00:14:24:08 - 00:14:35:13<br> Ashley Thompson<br> And I want our members to know that this the staff team at AHA is really committed to doing so, to really making sure that you have the resources that you need in order to care for your patients. </p> <p> 00:14:35:15 - 00:14:44:00<br> Stacey Hughes<br> Yeah, so well said. I would just add, you know, we think about the year, reflecting back between Change Healthcare, OneBlood supply in Florida and Baxter. </p> <p> 00:14:44:03 - 00:15:04:12<br> Stacey Hughes<br> And that was just weeks ago, if you really think about it in terms of the need for the association with your leadership and others, Tina, to really jump in and problem solve quickly and mitigate those types of issues. But I'll just say going into the year, I think I've kind of beaten that drum a little bit. But you know, we are, as Ashley said, we are working so far, the policy team and others to bring forth data. </p> <p> 00:15:04:18 - 00:15:22:11<br> Stacey Hughes<br> One of the ways that we win these battles is being able to tell a story with very specific data. We've got some pretty difficult issues, one of which is extending the ACA subsidies, I think Ashley mentioned. Knowing what that looks like to your hospital. How does it affect your bottom line? How does it affect patients? How does it affect the insurance coverage? </p> <p> 00:15:22:11 - 00:15:45:18<br> Stacey Hughes<br> I think that's true for Medicaid. So when we put all this stuff together, really would encourage everyone or field to take that information and help tell the story and amplify as much as we can. We'll do all the work for you in terms of making sure that we get you guys what you need to be able to understand the implications of some of these policies, but really just, welcome everyone's ability to engage with their members of Congress. </p> <p> 00:15:45:18 - 00:15:49:10<br> Stacey Hughes<br> So, that's my final note, I would say, Tina, in terms of the year ahead. </p> <p> 00:15:49:13 - 00:16:12:15<br> Tina Freese Decker<br> That's perfect. So thank you so much for your time today. And I really enjoy working with you and working with your teams. As you both said: the AHA teams are all in, we're ready to go. We're excited, we're passionate. This is you know what gets us up in the morning moving forward. And we need that partnership with our member hospitals and health systems to make sure we have the data and the stories and the connection there. </p> <p> 00:16:12:18 - 00:16:33:05<br> Tina Freese Decker<br> So it really takes this whole ecosystem to come together to make an impact and to make an impact for policies, the regulations that are coming forth, most importantly, so we can do an even better job taking care of our communities and improving health. And so we're so grateful for all the work that you and your teams are doing at the ���������� Association. </p> <p> 00:16:33:08 - 00:16:50:11<br> Tina Freese Decker<br> I know that it's going to be a tough year but with the focus and the energy, I think we can accomplish a lot of things. So thank you so much. To all of our members listening in, thank you so much for joining us today. And we'll be back next month for another Leadership Dialogue conversation. </p> <p> 00:16:50:13 - 00:16:58:24<br> Tom Haederle<br> Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts. </p> </details> </div> Mon, 27 Jan 2025 08:22:51 -0600 Marketplace Issues/Stability /news/headline/2025-01-14-cms-finalizes-notice-benefit-and-payment-parameters-2026 <p>The Centers for Medicare & Medicaid Services Jan. 13 <a href="https://www.federalregister.gov/public-inspection/2025-00640/patient-protection-and-affordable-care-act-hhs-notice-of-benefit-and-payment-parameters-for-2026">released</a> its standards for the health insurance marketplaces for 2026, including the issuers and brokers who assist marketplace enrollees. The final rule enhances CMS' authority to address and curtail misconduct by agents and brokers, such as fraudulent changes to an enrollee's health care coverage.  </p><p>CMS also finalizes updates to the risk adjustment program, medical loss ratio calculations and essential community provider certification review process, among other changes. Notably, CMS finalizes several policies to help enrollees better understand their costs and maintain coverage, such as updates to the premium payment threshold and a new enrollee notification process around tax filing and advanced premium tax credits. The final rule goes into effect Jan. 15.</p><p> </p> Tue, 14 Jan 2025 15:37:31 -0600 Marketplace Issues/Stability <div class="container"><div class="row"><div class="col-md-8"><p>The Centers for Medicare & Medicaid Services (CMS) Jan. 13 released its <a href="https://www.federalregister.gov/public-inspection/2025-00640/patient-protection-and-affordable-care-act-hhs-notice-of-benefit-and-payment-parameters-for-2026">standards</a> for the health insurance marketplaces, including the issuers and brokers who assist marketplace enrollees, for 2026. The final rule enhances CMS' authority to address and curtail misconduct by agents and brokers, such as fraudulent changes to an enrollee's health care coverage. CMS also finalized updates to the risk adjustment program, medical loss ratio calculations, and essential community provider certification review process, among other changes. Notably, CMS finalized several policies to help enrollees better understand their costs and maintain coverage, such as updates to the premium payment threshold and a new enrollee notification process around tax filing and advanced premium tax credits. The final rule goes into effect on Jan. 15, 2025.</p><h2>Major Provisions</h2><h3>Agent and Broker Oversight</h3><p>CMS finalizes several policies that increase oversight of agents and brokers that help consumers enroll in marketplace plans, to curtail misconduct such as fraudulent changes to individual’s health insurance coverage. These new policies:</p><ul><li>Strengthen CMS’ ability to investigate agents and brokers, undertake compliance reviews and take enforcement actions related to misconduct or noncompliance with marketplace standards. Through these policies, CMS will hold lead agents of insurance agencies accountable for misconduct or noncompliance.</li><li>Expand CMS’ authority to suspend agents and brokers who violate marketplace standards of conduct. This includes actions that pose an unacceptable risk to the accuracy of eligibility determinations, marketplace operations and IT systems, or applicants' or enrollees' private information.</li><li>Update the model consent form that agents and brokers can use to obtain and document consumer consent to help with the marketplace enrollment process.</li></ul><h3>Coverage Protections</h3><p>CMS finalizes several policies that will help ensure consumers can maintain their coverage in certain circumstances, including:</p><ul><li>Requiring issuers to implement new premium payment thresholds to enable consumers to maintain coverage even if they have not paid their full premium amount. Issuers can implement either a fixed-dollar premium threshold or one of two different percentage-based thresholds. The chosen premium payment threshold must be applied uniformly to all enrollees. </li><li>Requiring marketplaces to notify enrollees (or their designees) who are at risk of losing the advance premium tax credit (APTC) because they have not filed income taxes for two consecutive years.</li></ul><h3>Medical Loss Ratio</h3><p>CMS finalizes an update to the medical loss ratio (MLR) regulations so that net risk adjustment amounts can apply to the denominator rather than the numerator in MLR calculations for qualifying insurers. This policy is intended to incentivize issuers to focus on underserved communities with higher rates of significant health needs.</p><h3>Essential Community Providers</h3><p>CMS will conduct the essential community provider reviews for all qualified health plans (QHP) on the federally facilitated marketplace (FFM), even in states that perform plan management functions.</p><h3>Basic Health Program</h3><p>CMS finalizes updates to Basic Health Program (BHP) calculations, including recalculating the premium adjustment factor in instances when a BHP was only partially implemented in the state.</p><h3>Standardized Plan Options</h3><p>CMS finalizes minor updates to the standardized plan options, such as requiring issuers that offer multiple standardized plan options within a product network type, metal level and service area to ensure that there are meaningful differences between the plans.</p><h3>Transparency</h3><p>CMS will increase publicly available data on the marketplaces and marketplace issuers, including some state-based marketplace operational data and aggregated, summary-level Quality Improvement Strategy information.</p><h3>State-based Marketplace Timeliness Standards</h3><p>CMS codifies guidance for state-based marketplaces related to its review and resolution of enrollment data inaccuracies to ensure accurate and timely APTC payments.</p><h3>QHP Certification Reconsiderations</h3><p>CMS updates the process on the FFM for QHPs to request reconsideration of a certification denial. CMS clarified that a marketplace could deny QHPs certification if they do not meet certain criteria.</p><h3>Risk Adjustment</h3><p>CMS finalizes several changes to the risk adjustment program, including using 2020, 2021 and 2022 enrollee-level EDGE data for model recalibration, consistent with prior years, and changes to the initial and second validation audit sampling. CMS finalizes a risk adjustment user fee for the 2026 benefit year of $0.20 per member per month, which is slightly higher than the user fee rate used for the 2025 benefit year ($0.18).</p><h3>User Fees</h3><p>CMS increases the FFM user fee rate to 2.5% of monthly premiums in 2026, up from 1.5% in 2025, and the state-based marketplace on the federal platform (SBM-FP) user fee rate to 2.0%, up from 1.2%. CMS also finalizes alternative user fee rates of 2.2% (FFM) and 1.8% (SBM-FP) if the enhanced premium tax credit subsidies are extended through 2026.</p><h3>Silver Loading</h3><p>CMS codifies language reaffirming that silver-loading practices are permissible as long as they are actuarially justified and follow relevant state laws.<sup>1</sup></p><p><u></u></p><h3>Actuarial Value Calculator</h3><p>Following a request for comment, CMS finalizes revisions to the methodology for updating the Actuarial Value (AV) calculator so that the agency can publish a single, final version of the calculator each year, starting with the 2026 AV calculator.</p><h3>Medical Debt</h3><p>In the proposed rule, CMS requested comments on how navigators and assisters, specifically those assisters who work within a hospital or health system, can help connect consumers to financial assistance programs within hospitals and the community, including those programs intended to relieve medical debt. In the final rule, CMS acknowledges the comments and notes it may consider them in future rulemaking.</p><h2>Further Questions</h2><p>For more information, contact Ariel Levin, AHA’s director of coverage policy, at <a href="mailto:alevin@aha.org">alevin@aha.org</a>.</p><p>__________</p><p><small class="sm"><sup>1</sup> Silver-loading is a practice that allows insurers to increase silver-level premiums to offset lower cost-sharing requirements for enrollees. This practice began in response to the termination of cost-sharing reduction payments to issuers in 2017.</small><br> </p></div><div class="col-md-4"><a href="/system/files/media/file/2025/01/cms-finalizes-notice-of-benefit-and-payment-parameters-for-2026-advisory-1-14-2025.pdf"><img src="/sites/default/files/inline-images/cover-cms-finalizes-notice-of-benefit-and-payment-parameters-for-2026-advisory-1-14-2025-f.png" data-entity-uuid="e7317053-184b-472d-abda-1cd4d2a2cf9c" data-entity-type="file" alt="Cover of the Regulatory Advisory" width="640" height="834"></a></div></div></div> Tue, 14 Jan 2025 15:22:12 -0600 Marketplace Issues/Stability <div class="container"><div class="row"><div class="col-md-8"><p>The Centers for Medicare & Medicaid Services (CMS) Oct. 4 released its <a href="https://www.cms.gov/newsroom/fact-sheets/hhs-notice-benefit-and-payment-parameters-2026-proposed-rule" title="Original URL: https://email.advocacy.aha.org/NzEwLVpMTC02NTEAAAGWB9YSGFkBjwYNrXTWlhMWIR__6CaXyRPGct7-4Q1HpnuP6spg-9uYp06FRohLmNPX2Z-ITxg=. Click or tap if you trust this link.">proposed standards</a> for the health insurance marketplaces, including the issuers and brokers who assist marketplace enrollees, for 2026. The <a href="https://www.federalregister.gov/public-inspection/2024-23103/patient-protection-and-affordable-care-act-notice-of-benefit-and-payment-parameters-for-2026-and" title="Original URL: https://email.advocacy.aha.org/NzEwLVpMTC02NTEAAAGWB9YSGD1X3a564VB-5QJpf-P_CsZBNx31SPedmQy2CacdKIuAOrMI5yHukmTQXxQ0vA4K86s=. Click or tap if you trust this link.">proposed rule</a> would enhance CMS' authority to address and curtail misconduct by agents and brokers, such as fraudulent changes to an enrollee's health care coverage. The proposed rule also includes updates to the risk adjustment program, medical loss ratio calculations, and essential community provider certification review process, among other changes. Notably, CMS proposed several updates to help enrollees understand their costs and maintain coverage, such as updates to the premium payment threshold and a new enrollee notification process around tax filing and advanced premium tax credits.</p><h2>MAJOR PROVISIONS</h2><p><strong>Agent and Broker Oversight. </strong>CMS proposes several policies to increase oversight of agents and brokers that help consumers enroll in marketplace plans, to curtail misconduct such as fraudulent changes to individual’s health insurance coverage. These new policies would:</p><ul><li>Strengthen CMS’ ability to investigate agents and brokers, undertake compliance reviews and take enforcement actions related to misconduct or noncompliance with marketplace standards. Through these policies, CMS proposes to hold lead agents of insurance agencies accountable for misconduct or noncompliance.</li><li>Expand CMS’ authority to suspend agents and brokers who violate marketplace standards of conduct. This includes actions that pose an unacceptable risk to the accuracy of eligibility determinations, marketplace operations and IT systems, or applicants' or enrollees' private information.</li><li>Update the model consent form that agents and brokers can use to obtain and document consumer consent to help with the marketplace enrollment process.</li></ul><p><strong>Coverage Protections. </strong>CMS proposes several policies that would help ensure consumers can maintain their coverage in certain circumstances, including:</p><ul><li>Allowing issuers to implement new premium payment thresholds to enable consumers to maintain coverage even if they have not paid their full premium amount. Issuers could choose the implementation of either a fixed-dollar premium threshold or one of two different percentage-based thresholds.</li><li>Requiring marketplaces to notify enrollees (or their designees) who are at risk of losing the advance premium tax credit (APTC) because they have not filed income taxes for two consecutive years.</li></ul><p><strong>Medical Loss Ratio.</strong> CMS proposes to update the medical loss ratio (MLR) calculation so that net risk adjustment amounts apply to the denominator rather than the numerator. This policy is intended to incentivize issuers to focus on underserved communities with higher rates of significant health needs.</p><p><strong>Essential Community Providers.</strong> CMS proposes to conduct the essential community provider reviews for all qualified health plans (QHP) on the federally facilitated marketplace (FFM), even in states that perform plan management functions.</p><p><strong>Basic Health Program.</strong> CMS proposes updates to Basic Health Program (BHP) calculations, including recalculating the premium adjustment factor in instances when a BHP was only partially implemented in the state.</p><p><strong>Standardized Plan Options.</strong> CMS proposes minor updates to the standardized plan options, such as requiring issuers that offer multiple standardized plan options within a product network type, metal level, and service area to ensure that there are meaningful differences between the plans.</p><p><strong>Transparency. </strong>CMS proposes to increase publicly available data on the marketplaces and marketplace issuers, including State-based Marketplace Annual Reporting Tools (SMARTs) and accompanying financial and programmatic audits and aggregated, summary-level Quality Improvement Strategy (QIS) information.</p><p><strong>State-based Marketplace Timeliness Standards.</strong> CMS proposes formalizing guidance for state-based marketplaces related to its review and resolution of enrollment data inaccuracies to ensure accurate and timely APTC payments.</p><p><strong>QHP Certification Reconsiderations</strong>. CMS proposes updating the process on the FFM for QHPs to request reconsideration of a certification denial. CMS also proposes to clarify that a marketplace can deny QHPs certification if they do not meet certain criteria.</p><p><strong>Risk Adjustment.</strong> CMS proposes several changes to the risk adjustment program, including using 2020, 2021 and 2022 enrollee-level EDGE data for model recalibration, consistent with prior years, and changes to the initial and second validation audit sampling. CMS proposes a risk adjustment user fee for the 2026 benefit year of $0.18 per member per month, which is the same user fee rate used for the 2025 benefit year.</p><p><strong>User Fees.</strong> CMS proposes to increase the FFM user fee rate to 2.5% in 2026, up from 1.5% in 2025, and the state-based marketplace on the federal platform user fee rate to 2.0%, up from 1.2%. However, CMS notes if the enhanced premium tax credit subsidies are extended through 2026, it will finalize lower user fees.</p><p><strong>Requests for Comment. </strong>CMS also requests comments on a number of issues in the proposed rule, including:</p><ul><li><u>Medical Debt.</u> CMS requests comments on how navigators and assisters, specifically those assisters who work within a hospital or health system, can help connect consumers to financial assistance programs within hospitals and the community, including those programs intended to relieve medical debt.</li><li><u>Silver Loading.</u> In the proposal, CMS reaffirms that silver-loading practices are permissible.<sup>1</sup> Given continued questions about this practice, CMS requests comments on whether and how to codify the agency’s earlier guidance on this practice.</li><li><u>Issuer Insolvency.</u> CMS requests comments on ways to reduce the risk of financial insolvency for insurance issuers to ensure consumers do not lose access to health insurance coverage options.</li><li><u>Actuarial Value Calculator.</u> CMS plans to revise the methodology for updating the Actuarial Value (AV) calculator so that the agency can publish a single, final version of the calculator each year, starting with the 2026 AV calculator. However, CMS is still open to additional comments on the AV calculator, which could be adopted in future updates.</li></ul><h2>FURTHER QUESTIONS</h2><p>Comments on the proposed rule are due Nov. 12, 2024. For more information, contact Ariel Levin, AHA’s director of coverage policy, at <a href="mailto:alevin@aha.org">alevin@aha.org</a>.<br> </p><p> </p><p> </p><p> </p><p>__________</p><p><small class="sm"><sup>1 </sup>Silver-loading is a practice that allows insurers to increase silver-level premiums to offset lower cost-sharing requirements. This practice began in response to the termination of cost-sharing reduction payments to issuers in 2017.</small></p></div><div class="col-md-4"><a href="/system/files/media/file/2024/10/cms-issues-proposed-notice-of-benefit-and-payment-parameters-for-2026-bulletin-10-9-2024.pdf"><img src="/sites/default/files/inline-images/cover-cms-issues-proposed-notice-of-benefit-and-payment-parameters-for-2026-bulletin-10-9-2024_0.png" data-entity-uuid="a721d3b7-e5fb-443d-84d9-e8136608e9dc" data-entity-type="file" alt="Special Bulletin Cover" width="679" height="878"></a></div></div></div> Wed, 09 Oct 2024 02:10:17 -0500 Marketplace Issues/Stability /news/headline/2024-10-07-cms-issues-proposed-notice-benefit-and-payment-parameters-2026 <p>The Centers for Medicare & Medicaid Services Oct. 4 released its <a href="https://www.cms.gov/newsroom/fact-sheets/hhs-notice-benefit-and-payment-parameters-2026-proposed-rule">proposed standards</a> for the health insurance marketplaces, including the issuers and brokers who assist marketplace enrollees, for 2026. The <a href="https://www.federalregister.gov/public-inspection/2024-23103/patient-protection-and-affordable-care-act-notice-of-benefit-and-payment-parameters-for-2026-and">proposed rule</a> would enhance CMS' authority to address and curtail bad behavior by agents and brokers, such as fraudulent changes to an enrollee's health care coverage. The proposed rule also includes updates to the risk adjustment program, medical loss ratio calculations, and essential community provider certification review process, among other changes. Notably, CMS proposed several updates that would help enrollees understand their costs and maintain coverage, such as updates to the standardized plan options and a new enrollee notification process around tax filing and advanced premium tax credits.</p> Mon, 07 Oct 2024 16:02:34 -0500 Marketplace Issues/Stability