Repeal and replace is on-again, off-again, but that doesn't mean the rules affecting your insurance will stay the same in the meantime.
The Trump administration's proposed rule aimed at stabilizing the existing health law's insurance marketplace could have rapid, dramatic effects — perhaps as soon as early summer — on people who do not get insurance through work, and buy it on the Affordable Care Act's exchanges instead.
If the changes the administration proposed in February hold up in the final draft, which is expected out soon, look for a shorter enrollment window, tighter vetting of people who sign up outside of those open periods and efforts to penalize consumers who don't maintain "continuous coverage."
The controversial proposal by the Department of Health and Human Services drew letters from nearly 4,000 organizations and individuals during an unusually short, 20-day public comment period that ended in early March. Consumer advocacy groups hate the proposal, saying it would wreak havoc by making it harder to get coverage.
But some specialists in the health law, including Christopher Condeluci of CC Law & Policy in Washington, D.C., see the HHS proposal as helpful for insurers, though he also thinks more adjustments are necessary.
"Does it meet all the carriers' asks when it comes to what changes are needed? No, I don't think it goes far enough," said Condeluci, a former staffer to the Senate Finance Committee who specialized in insurance issues.
Sabrina Corlette, an attorney who studies the individual marketplace for the Center on Health Insurance Reforms at Georgetown University, said the directive could result in fewer healthy enrollees — which insurers also would not like — and doesn't address some of the biggest concerns for the insurance industry, such as the fate of federal subsidies that help low-income consumers pay deductibles and other out-of-pocket costs.
The Trump administration's proposal, Corlette said, is "nibbling away at the margins."
Here are four ways the stabilization rule might change the individual health insurance market:
If you owe, you pay first
Under the proposed rule, consumers who want to sign up for an ACA plan with their same insurer for 2018 would have to repay past-due premiums from the previous 12 months before being granted new coverage. Because Obamacare has allowed a three-month grace period before people who haven't paid premiums are kicked out of coverage, a consumer's overdue premiums could tally hundreds of dollars — even more than $1,000.
Trump's proposed change aims to discourage people from gaming the system. Insurers say a person with a bad knee, for example, might enroll and pay just long enough to get an expensive knee replacement, then stop paying premiums.
But wait, consumer groups and the National Association of Insurance Commissioners warn. There might be legitimate reasons people stop paying premiums — billing errors that are not the fault of the consumer, for example, or the loss of a job. By making such a change, the groups argue, the Trump administration would violate a key part of the health law that requires insurers to offer coverage to just about everyone who applies.
Under Trump's proposed change, "only those who can rapidly come up with a possibly significant sum of money by a given deadline can be guaranteed access to coverage," wrote Families USA.
Some insurers have recommended broadening that proposal to include "unpaid premiums for any prior coverage year."
Better act quickly
Open enrollment this fall (for 2018 health insurance coverage) would shorten to six weeks, down from three months. While opening day would remain the same — Nov. 1 — the proposal would close the marketplace on Dec. 15 instead of at the end of January. That period "provides sufficient time for consumers to enroll," the administration has said, and would mean all who sign up would have a full year of coverage starting Jan. 1.
The shorter time period, the administration said, could also reduce the number of people who wait to enroll until after they find out they have a health problem. These late joiners are likely to use more health care than a healthy person their age, insurers and the Trump administration say, and can drive up the cost of insurance to everyone.
Consumer groups argue the Trump proposal could backfire, because those who tend to wait until the last minute to sign up are actually often the youngest and healthiest — and they may miss the enrollment window if it is shorter. Additionally, the proposed deadline falls around the holidays, when money and time are often tight, which could have a chilling effect on insurance sign-ups.
Prove you have a reason — and maybe prior coverage
The ACA allows people to sign up outside the open enrollment period for a variety of special reasons, such as moving, losing coverage, getting married or having a child. This provision has always been a sticking point with insurers, who have maintained that too many customers who made a change during the special enrollment period were sicker and costlier than average. In response, the Obama administration tightened some of these requirements last year and announced it would run a pilot program starting this summer to randomly select half of all special enrollment applicants for verification review, holding up the applicant's insurance coverage until they provide the proper documentation.
Under the Trump administration's proposal, 100 percent of those applications would be required to undergo preapproval verification — beginning in June 2017. Consumers would have to provide documentation proving they qualify for special enrollment before getting coverage. The administration also proposes that for marriage, at a minimum, one member of the couple would have to prove they had health coverage for at least one day in the two months before their nuptials.
Consumer groups are unhappy with the pre-verification idea — and the extra requirement for prior coverage of people who are getting married. Particularly hard hit would be couples who were uninsured previously because they could not afford health insurance as singles or could not get it under their state's Medicaid rules. Additionally, consumer advocates and some regulators say requiring newlyweds to prove prior coverage violates the health law.
Still, the Trump administration asked whether continuous coverage rules should be extended to all special-enrollment customers, not just those getting married. Perhaps people should prove they had coverage for the previous six to 12 months, the administration suggested, or else face a waiting period or financial penalty.
Flexibility — or higher deductibles?
The health law uses a complex formula to divide plans into metal tiers — bronze, silver, gold and platinum — based on an average percentage of a typical year's health care bills each level of plan covers. Bronze plans, for example, currently must cover an average of 60 percent of costs, while a silver one is 70 percent. Insurers are allowed wiggle room of plus or minus 2 percent around those averages.
The Trump proposal would tweak the formula, allowing insurers to create plans with larger variations around the average. (It exempts certain silver plans for low-income consumers from the change.) So, for example, a bronze plan might cover only 56 percent of costs and silver 66 percent. Insurers say this would allow them to create plans that appeal to more customers, particularly those looking for lower premiums. But critics say the move would increase the size of deductibles.
One big problem in boosting enrollment has been that many potential consumers — particularly younger, healthier ones — say premiums are too high. But adjusting the law in this way could raise deductibles and other cost-sharing requirements, which consumers may dislike even more. While the health law sets a maximum cap per year on such payments, for many people those deductibles are already thousands of dollars annually. Under the proposal, deductibles could increase by more than $1,000 a year, according to an analysis by the consumer advocacy group Families USA.
Please, may I have some more?
Topping insurers' wish list for other changes, which would require legislative action by Congress, would be permanent federal financial support for insurers that face high-dollar claims from some policyholders. Insurers have argued that change is important if they are to hold down premium costs across the board. Insurers also want a surcharge for people who let their coverage lapse, and the permission to charge older people five times more than younger ones, a practice known as "age rating." The current limit is 3:1. Widening that ratio could lower premiums for young people but cause big hikes for people older than 45.
Cigna said it would like to see an "appropriately funded system of state-designed high-risk pools," where people with costly illnesses could be sent. So, those with cancer, heart disease or other illnesses would be shunted into those pools, reducing spending — and perhaps premiums — for all remaining in the regular pool. High-risk pools historically, however, have been underfunded, often leading to expensive premiums for enrollees, long waitlists or annual limits on care.
Kaiser Health News, a nonprofit health newsroom whose stories appear in news outlets nationwide, is an editorially independent part of the Kaiser Family Foundation.