Insurance experts are watching Washington to see how new rules on health insurance will affect premiums and plans available to consumers on and off the exchanges.

“The prognosis is that the (Affordable Care Act) market is not collapsing, but it’s not a bed of roses,” said Sabrina Corlette, a research professor at Georgetown University’s Health Policy Institute during a briefing organized by the Commonwealth Fund, a nonprofit, non-partisan health care foundation.

The people eligible for subsidies will continue to be insulated from premium increases, but those who make too much to qualify will continue to have a hard time finding affordable individual policies on or off the market.

“It’s rendering major medical unaffordable for most people,” shopping on the individual plan market, Corlette said.

Mississippi Insurance Commissioner Mike Chaney said his department is closely watching for rules on how association health plans and short-term policies will be governed.

“The big concern with association health insurance is will insurance commissioners return authority over their plans,” said Bob Williams, director of Life & Health Actuarial Division of the Mississippi Insurance Department.

Wider use of short-term plans could be a benefit for those who are between jobs and can’t afford a COBRA to continue their old insurance, Chaney said. The plans are currently limited to 90 days; proposed rules are considering allowing them to be extended for year.

“That could be a real benefit,” Chaney said.

Unlike ACA-compliant plans, the short term plans are able to exclude those with pre-existing conditions.

The Mississippi Insurance Department is also waiting to hear if its waiver for short-term group insurance will be extended again. The extensions from both the Obama and Trump administrations have allowed the insurance department to help the small groups who have relied on the policies to transition smoothly without being hit with exorbitant increases.

The insurance department is also exploring options that might allow pathways for low-income Mississippians to access some health care coverage, Chaney said.

“We’re looking for flexibility on non-ACA compliant policies,” Chaney said.

ACA payment rule

During the Commonwealth Fund briefing, Corlette and Matthew Fiedler, a fellow with the Center for Health Policy at the Brookings Institution, highlighted some of the most significant provisions of the proposed regulations in the ACA payment rule. The proposed rule was released for comment in October and a final rule is expected shortly. Both Fiedler and Corlette said they expect the rule to track closely with the proposed changes, although there could be surprises.

The proposed rule would give states a lot of flexibility in determining the essential health benefits, both in terms of the broad categories and then defining what is covered within those categories, Fiedler said. Right now, the Department of Health and Human Services, which governs the exchanges, gives states a menu of high enrollment employer plans to use as benchmarks. Under the proposed rule, states could pick from plans across the country or create their own

“It would likely prevent the elimination (of an entire category of health benefit) but it it gives them room to significantly narrow it,” Fiedler said.

“If even one state decides to narrow (essential health benefits) you could see changes in large plans nationwide,” Fiedler said.

Depending on how HHS intends to set the regulations and enforce them, insurers could use the substantially equal provisions to offer more outpatient services and fewer inpatient services, Fiedler said. It could result in shifting costs to sicker patients.

In Mississippi, Chaney as insurance commissioner sets the essential health benefits, and he reiterated that he has no intention of changing them.

The proposed rules would further reduce the navigator program, which provided trained, in-person sign-up support, Corlette said. Current rules require navigator grants go to at least two organizations in each state, one of which had to be a community-based organization.

The proposed rule also would decrease direct enrollment where consumers bypass the healthcare.gov website to enroll through in-person and online brokers.

“There’s an increasing sense that HHS wants direct enrollment to become a much bigger pathway,” Corlette said. That could be positive, allowing more avenues to enroll and incentives for brokers. It could be troublesome if there’s consumer confusion over ACA-compliant plans and non-compliant short term plans.

There is some question about if the proposed payment rule will go into effect for next year, Corlette said. During the public comment period, some insurers have said the proposed changes are so sweeping, it would be impossible to implement in 2019, especially since the final rule is about a month behind when the final rules have been published previously.

Rate forecast

Based on current conditions, Chaney anticipates that rates for group health insurance will remain level or even decline. He expects individual plans not on the exchange could increase by 10 to 12 percent.

Ambetter by Magnolia has indicated it plans to remain on the federal health insurance exchange in all 82 counties in Mississippi, Chaney said.

“My educated guess is that rates will not go up more than 4 or 5 percent,” Chaney said.

Instead of loading price increases onto silver level plans on the exchange, which are used to set subsidies, Chaney has opted not to have any increases because of the loss of cost-sharing reduction payments spread across all exchange plans.

“If we spread it, the tax credit is more equalized for all consumers,” Chaney said. “We’re trying to be fair to everybody.”

Some states have allowed the increases to be loaded onto the silver tier, which can stretch the subsidies farther for bronze level plans. However, it can significantly increase costs for consumers that need silver level plans and don’t qualify for subsides.

— By Michaela Gibson Morris / Daily Journal