CMS Final Rule Mandates Separate Billing for Abortion Services in State Exchanges

Abortion rights advocates say the new rule continues the Trump administration's 'attack on patients and their ability to obtain health are coverage for abortion care.'

The Centers for Medicare & Medicaid Services issued a final rule Friday that mandates separate billing and collection for abortion services coverage provided by state exchange plans under the Affordable Care Act.

"The rule better aligns with Congress' intent that qualified health plans collect two distinct payments, one for the coverage of abortion services, and one for coverage of all other services covered under a Qualified Health Plan," CMS said in a media release.

Health and Human Services Secretary Alex Azar called the separate billing requirement "an essential step in implementing the Affordable Care Act's bar on tax credits going toward coverage of abortions for which public funding is prohibited."

The requirements are part of a broader package of regulations in the Exchange Program Integrity Final Rule, which federal policymakers say will strengthen oversight of state-based exchanges and ensure beneficiaries' eligibility for premium subsidies.

"Pursuant to the law, this rule will ensure that taxpayers do not contribute funds to pay for coverage of abortion services for which funding isn't allowed by law, and will alert consumers that their health plan covers abortion services, allowing them to make fully informed decisions about their coverage," CMS said.

'A Non-solution'

Margaret A. Murray, CEO of the Association of Community Affiliated Plans, called sending beneficiaries two separate bills every month "a non-solution in search of a problem."

"This misguided rule will only succeed in introducing confusion to the Marketplace on a massive scale, and put millions of consumers at risk of losing their coverage," she said.

Murray noted that failure to pay both bills each month could jeopardize coverage for beneficiaries.

"It’s hard to think of another industry where the government mandates, as the Trump administration would here, that consumers cut two checks a month for the same service," she said. "This rule is a departure from standard accounting practices and imposes operational and financial challenges for plans as they work to comply with the separate billing requirements. But the most significant burdens of this rule fall on the consumer."

The added and needless complexity and administrative burden of the new rule imposed upon insurers and consumers could also lead health plans to drop abortion coverage, she said. 

"This provision of the Program Integrity rule will wrap Marketplace coverage in red tape," Murray said. "The administration should withdraw these requirements immediately."  

April Lockley, MD, a family medicine physician in New York and Fellow with Physicians for Reproductive Health, said the new rule continues the Trump administration's "attack on patients and their ability to obtain health are coverage for abortion care."

"Navigating the confusing medical insurance industry is already difficult enough and this new rule further burdens patients," she said.

Margarida Jorge, executive director of Healthcare for America Now, called the final rule "just another example of the Trump administration's concerted efforts to strip abortion access from millions of people."

"This extra bureaucracy is aimed at causing confusion among consumers, stigmatizing abortion and limiting access to insurance coverage for abortion by discouraging insurers from offering this coverage," she said.  

Jorge urged insurers to "take a stand against this burdensome rule and continue offering coverage for reproductive health services, including abortion care."

Under the new final rule, state-based exchanges will be required to conduct ongoing eligibility verifications with outside data sources at least twice a year, CMS said.

In addition, the rule aligns federal regulations with the statutory requirements of the ACA to help ensure consumers understand the coverage they are buying.

With the new requirements in place, CMS said it will be able to better identify and correct eligibility and enrollment issues sooner, which can minimize the time consumers inadvertently receive tax credits that they will have to pay back later, and mitigate risks that they are paying premiums for a plan they no longer need.

The separate billing requirements in the final rule become effective June 27, 2020. The rest of the final rule takes effect nationwide in February 2020.

CMS said the final rule was crafted after the HHS Office of Inspector General and the Government Accountability Office identified weaknesses in the process for determining eligibility for advance payments of the premium tax credit (APTC) and cost-sharing reductions (CSR) in both state and federal exchanges.

The rule enhances oversight of state-based exchange program reporting to confirm states are correctly identifying eligible enrollees, including those who are qualified for APTC and CSRs, CMS said.

In addition:

• CMS is finalizing changes that clarify the scope of such annual SBE audits, including procedures to test eligibility and enrollment transactions to ensure SBEs that operate their own eligibility and enrollment platforms are properly determining consumer eligibility for QHPs, APTC and CSRs.
   
• The rule also implements safeguards regarding the eligibility and enrollment process across all Exchanges, including SBEs, State-based Exchanges on the Federal Platform, and Federally facilitated Exchanges. This includes enhanced periodic data matching that will allow CMS to more frequently identify and resolve issues related to consumers who are dually enrolled in both Medicare and a QHP through the Exchange.

"This will ensure that people are enrolled in the most appropriate type of coverage for them," CMS said. "Beginning with plan year 2020, CMS will require SBEs to conduct Medicare, Medicaid/CHIP, and as applicable, Basic Health Plan periodic data matching at least twice a year for QHP enrollees who receive subsidies."