The Centers for Medicare & Medicaid Services (CMS) finalized the Notice of Benefit and Payment Parameters for 2019 and released new guidance expanding the hardship exemption from the requirement to have coverage or pay a penalty.

↓ Read the final rule

↓ Read the guidance on hardship exemptions 

For an overview of the rule changes, see our paper, “Health Care Rule Changes Will Harm Consumers,” detailing how these changes will weaken benefit standards, likely harming people with pre-existing conditions; raising new barriers for people who want to enroll in health coverage; and reducing accountability for insurers and transparency for consumers.

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Changes from the final rule and additional guidance include:

Altered rules for navigator programs.  Under the rule, marketplaces are permitted to have just one navigator entity serve the entire state. In addition, the rule allows navigators to not have a physical presence in the state they are paid to serve and no longer requires that one navigator group in a service area be a consumer-focused nonprofit organization.

New requirements for verification of income.  The rule requires individuals to verify their income if their attested income is above the poverty line but data sources suggest that income is below the poverty line. This will make it harder for eligible individuals with fluctuating poverty-level income to access much-needed financial help to afford coverage.

Expanded hardship exemption.  Effective immediately, new guidance expands the situations in which people can receive a hardship exemption to include people who:

• Show that a lack of choice when there is only one issuer in their area “precluded” them from obtaining coverage;
• Cannot buy an affordable plan that does not include abortion coverage, which is contrary to the individual’s beliefs;
• Have no qualified health plan in their area (a circumstance no marketplaces have ever experienced); or
• Experience personal circumstances that may qualify as a hardship, such as when available QHPs don’t cover needed specialty care.

New special enrollment period (SEP) for loss of pregnancy-related coverage provided through CHIP.  The rule adds an additional SEP for the loss of coverage provided through the Children’s Health Insurance Program (CHIP) “unborn child” option, which only covers pregnancy-related services and is not considered minimum essential coverage. This SEP will go into effect on June 18, 2018.

Removes requirement to provide adequate notice to those who fail to reconcile APTC.  People who receive APTC are required to file a tax return and reconcile the tax credit, or they risk losing financial assistance when they re-enroll. Current rules require that the Marketplace must first provide enrollees with information about failure to reconcile, giving them a chance to correct the record if they in fact reconciled or remedy the situation by filing a tax return, but the new rule removes that requirement to first send notice directly to the tax filer before discontinuing APTC.

Allows states and insurers to scale back benefits.  Beginning in 2020, the new rule changes the standards for how states create a benchmark plan to establish the minimum standard for the ten essential health benefits offered in that state and how insurers comply with them, opening up new ways for states and insurers to scale back coverage of services that are costly but critical to people with serious health needs.

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There are additional changes in the rule including weakening the risk adjustment program by letting states shrink risk adjustment transfers by up to 50%, reduced transparency of insurance premium rates, and diminished standards for the “medical-loss ratio” requiring insurers to spend at least 80% of what they collect in premiums on medical care and improving healthcare quality. For more detailed information on the harmful changes in this rule, please see our paper, “Health Care Rule Changes Will Harm Consumers.”