By Stacey Kusterbeck, Contributing Writer, Relias-AHC Media

The federal government is giving insurers and states more flexibility to increase access to affordable health plans. The HHS Notice of Benefit and Payment Parameters for 2019, issued by The Centers for Medicare & Medicaid Services (CMS):

  • returns important oversight authority to states regarding review of network adequacy;
  • eliminates the meaningful difference requirement for qualified health plans, giving insurers more flexibility in designing plans;
  • provides states with more flexibility as to what benefits are included in plans.

Under the Affordable Care Act, 10 essential health benefits are required. These include prescription drugs as well as maternity and newborn care. The new regulations expand the essential health benefits to 50 options.

“Too many Americans are facing skyrocketing premiums that they can’t afford, and every year consumers are faced with the threat of fewer choices. This rule gives states new tools to stabilize their health insurance markets and empower citizens to find coverage that fits their families’ needs and budgets,” CMS administrator Seema Verma said in a statement.

The ACA has priced many consumers out of the insurance market, according to CMS. However, cheaper plans are likely to mean higher out-of-pocket costs for patients -- and possible lost revenue for hospitals.

“Lower premiums typically lead to reduced benefits, more non-covered services, and more restricted site-of-service limitations,” says Sandra J. Wolfskill, FHFMA, director of healthcare finance policy at the Healthcare Finance Management Association.

Wolfskill says it’s “imperative” for patient access departments to:

  • develop a resource listing of the various plans offered in their markets;
  • when verifying eligibility and effective date of coverage, verify benefits and limitations.

It also would be useful to create new plan codes for these health plans. This allows providers to track overall plan performance, including shifting of any dollars into self-pay. “In future years, the provider has a solid history with which to negotiate rates with the payer,” Wolfskill explains.

In the upcoming June 2018 issue of Hospital Access Management, we report on how patient access departments are preparing for this change.