The Centers for Medicare and Medicaid Services, in a break from Biden-era policies, is proposing to shorten the open enrollment period for Affordable Care Act marketplace plans in a bid to curb "improper enrollments."
The proposed regulation would see open enrollment for the individual marketplace end on Dec.15, rather than in January.
CMS said access to fully subsidized premiums from the temporary increase in financial assistance enacted in 2021 – and the elimination of eligibility verification processes – greatly increased the opportunity and incentive for improper enrollments.
"Improper enrollments," in this case, means the number of applications submitted to HealthCare.gov with information that failed to match federal data sources, which the agency said began increasing substantially in 2021.
By 2022, the number of applications with data matching issues rose to 6.3 million, up from 2.6 million in 2020, said CMS.
WHAT'S THE IMPACT?
The agency estimated the new regulation would reduce improper federal spending on advance payments of the premium tax credit by $11 billion to $14 billion in 2027.
Another provision entails ending the availability of the monthly special enrollment period (SEP) for individuals with household incomes below 150% of the federal poverty level. The proposal would also require all marketplaces to reinstitute pre-enrollment verifications of eligibility for SEPs, and to require further verifications of income when there is no tax data available for verification.
The rule also proposes that when an enrollee does not verify their ongoing eligibility for a fully subsidized plan, marketplaces must continue to re-enroll that person into the same plan, but must also reduce the amount of advance payment of the premium tax credit by $5. This would require the enrollee to pay a $5 monthly premium until they confirm or update their eligibility determination.
CMS is also proposing a policy that would add "sex-trait modification" to the list of items and services that may not be covered as essential health benefits beginning in plan year 2026.
The proposed rule would also revert to a previous definition of "lawfully present" that excludes Deferred Action for Childhood Arrivals (DACA) recipients from enrolling in Marketplace coverage.
THE LARGER TREND
Close to 24 million people selected a health plan for 2025 during the ACA open enrollment period that ran from Nov. 1, 2024, to Jan. 15, 2025. According to data provided by CMS, of the 23.6 million people who signed up this year, 3.2 million are new consumers and 20 million have returned to the ACA marketplace. For 2024 coverage, 21.4 million people signed up at the end of last year's open enrollment period.
The result, said CMS, is a historically low uninsured rate.
Jeff Lagasse is editor of Healthcare Finance News.
Email: jlagasse@himss.org
Healthcare Finance News is a HIMSS Media publication.