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Commenters Knock HHS Rules on Health Insurance Exchanges

 |  By Margaret@example.com  
   November 03, 2011

Proposed rules don't give states enough time to establish health information exchanges and limit their flexibility and control over operating them, said roughly 30 organizations, including state governments, business groups, lobbyists, and special interest groups, in public comments. 

The Department of Health and Human Services proposed three rules to govern the creation and operation of state-based health insurance exchanges, as well as the employer standards and Medicaid eligibility related to them.

The framework for HIX was established in the Patient Protection and Affordable Care Act of 2010 and is scheduled to take effect in 2014. According to HHS, more than 25 states have launched efforts to create exchanges.

Here's a sampling of the comments posted in response to the proposed rules on regulations.gov:

America's Health Insurance Plans, the health plan industry's trade organization, filed 30 pages of comments. It's no surprise that AHIP supports putting insurers and insurance experts on HIX governance boards. The group recommends the Centers for Medicare & Medicaid Services, which will oversee the program, develop a common definition of quality improvement standards for all exchanges but with the flexibility to meet the needs of the local enrolled population. To balance affordability and provider access, AHIP warned CMS against taking additional steps to define network adequacy and sufficient essential community providers and instead adopt existing state law requirements pertaining to network adequacy.

The Association for Community Affiliated Plans, which represents safety net health plans with more than eight million enrollees in 28 states, recommended that states "be required to assess income on an annual basis to avoid situations where an individual is inappropriately determined ineligible for both Medicaid and HIX coverage." It also wants CMS to reduce any barriers that would limit the ability of safety net health plans to participate in HIX. ACAP said CMS should allow for a five-year transitional period for the health plans to build required reserves, a three-year transitional period to allow unaccredited plans to obtain the required accreditation, and two years to allow Medicaid-focused health plans to gain licensure.

Americans for Prosperity, a conservative think tank and grass roots organization, voiced its concern that states will not have enough control over HIX to meet local market needs. It said CMS created significant changes that would limit a state's ability to alter or control its own HIX without CMS approval. According to the comments, those changes include certification procedures and enrollment processes as well as IT systems. The group echoed a common concern that CMS has not given states enough time to establish exchanges.

 

Several states, including Louisiana, Ohio, and Oklahoma, submitted comments. Ohio officials asked for more flexibility in the federal-state partnership model. "States are more than capable and should have the ability to customize their state-based exchange by choosing additional options that the state is able to mange, while leveraging federal coordination of functions that make more sense handled nationally." Oklahoma officials questioned whether CMS should limit how and when to charge user fees. "Federal policy should not dictate how user fees can be handled at the state level and further restrictions on how the state may assess user fees are unnecessary. Additionally, the exchange may wish to collect assessments on a more regular basis, such as monthly."

Louisiana officials noted that the rule requires an exchange to verify annual household income information and current household income information. But since few data sources provide such real time information, it asked CMS to define what an exchange can accept as "current household income."

The National Association of Medicaid Directors asked federal agencies to make reporting and business process as easy as possible for states and consumers. "States believe they should not be asked to collect or report data that does not result in any substantial difference in the determination of coverage."

The Urban Institute, a bipartisan research organization, suggested more people would enroll in exchanges if open enrollment was early in the year so consumers' could use their most current tax forms to establish eligibility. This could reduce administrative expenses spent to analyze and validate other income documentation, the Institute said.

Rep. Renee Elmers (R-NC), who serves on the House Committee on Small Business, said the proposed rule "does not address the fundamental issues of determining the essential benefits package or the standards for individual eligibility in the exchange. These yet-to-be-determined issues will be vital to insurers in setting rates and employers making insurance purchasing decisions."

The Patients' Access to Responsible Care Alliance is a Northern California group that advocates for the mentally disabled. The group said proposed rules about regional or subsidiary exchanges are too vague and could hinder access to medical care. It recommended that state laws regarding provider scope of practice terms apply to the regional and subsidiary exchanges.

The National Business Group on Health, which represents 330 large employers, suggested states "insulate the exchanges from politics" and "set up non-profit entities to administer exchanges rather than base them at new or existing state agencies." It said CMS should require states to "share eligibility and enrollment information from their individual and small business health options exchanges to allow both the exchanges and employers to better identify individuals transitioning from different coverage."

When the rules were first proposed in July, HHS said it expected to have the final rules in place before the end of the year. However, the comment period was extended by 30 days to Oct. 31, which could delay the final rules. Efforts to confirm a timeline for the final rules were unsuccessful.

Margaret Dick Tocknell is a reporter/editor with HealthLeaders Media.
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