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Is there going to be individual health insurance for 2018?

I’m getting this question a lot. Well, the good news is I think we’ll have at least two solid insurers in California, and hopefully more, because our market has been so successful. Both Blue Shield and Kaiser are nonprofits totally committed to our state and community.

More immediately, I wanted to share with you some proposals from the Center for Medicare Services to try to stabilize the insecure insurance market for 2018. These are system tweaks that require no votes, but they are taking comments (and I've given them). No, I don’t know what insurance will cost or if we’ll have any tax subsidies. But I am confident we will at least have insurance choices!

If this is TL;DR, then just take a Red Pen in your calendar: Open Enrollment for 2018 starts 11/1 and ends 12/15. Start thinking about it at Halloween, make your decisions by Thanksgiving, and pay your January premiums before Christmas/Hannukah.

Under the ACA, health insurers were required to file their proposed benefit plans and rates by each Spring for the following year. The reason for the huge rate hikes in 2017 were largely due to the insurers having to file in March of 2016 based on claims experience from 2014, the first year of the ACA and a major adjustment period. Well, you can imagine the concern about filing for 2018 in the midst of the current political transition and discussions of repealing the ACA.

On February 15, CMS has proposed many changes that they hope will stabilize the individual and small group market for 2018 while future reform is being debated. It took several years to implement the ACA, and it will likely take several more for whatever comes next to be implemented.

  1. Prove it: Marketplaces were taking people’s word for it that they had a qualifying event that let them purchase insurance mid-year instead of during open enrollment or giving them up to 90 days to provide proof. CoveredCA’s mandate was “the more, the merrier”. Often these late entrants had significant claims. In 2018, will be required to documentation prior to letting someone enroll and within 30 days of the application. It is as yet unclear if will follow suit with 30 days, but most CA insurers requiring proof within 60 days.

  2. Stay current this year to keep it next year: Insurers will be able to deny coverage in 2018 if those members are past due on premiums from 2017. Currently an Exchange member can be past due for 90 days before cancellation, and then can start with a clean slate on January 1. This meant that the insurers were collecting only 9 months of premium for 12 months of risk.

  3. Silver Enhanced Advantage: Each metal tier has an actuarial value (Bronze = 60% of expected claims will be paid, Silver = 70%). Insurers had strict regulations to follow to meet these standardized Metal targets which resulted in some odd benefit plan designs and not much choice between tiers, but it also gave standardized options across insurers. CMS will allow for more flexibility so that more options can be offered. While I think people liked having just a few basic, comparable choices, I personally am hoping for a simple Bronze Plus plan. I’m sure the marketing departments are sharpening their pencils for confusing and crafty plan names.

  4. Is 1 neurologist enough? ACA requires that insurers provide sufficient provider access, but that definition was difficult to manage nationally and resulted in hefty lawsuits. Many insurers have been trying to market highly curated (a.k.a. narrow) networks with tight integration, with the goal of improving cost and quality outcomes. These narrow networks have largely been rejected by consumers in the Bay Area. CMS will now defer to the states to assess network adequacy.

  5. Too soon? Insurers are going to be given more time this year to file their plans for 2018 so they can incorporate the above guidance. This will only be a concern if this results in a rush job prior to Open Enrollment.

  6. Ho Ho Ho There: Because open enrollment is going to be fast and strict. Individuals are going to only have an open enrollment for January 1 which is proposed to be November 1 – December 15 for January 1. There will be no option to enroll with February or March effective dates. See my Red Pen Calendar Appointments above.

While the immediate concerns may be a bit delayed, our sight needs to be on the legislation coming down the pike that will impact us in 2020 and beyond. Our national healthcare spending is expected to reach 20% of our GDP in 8 years; without urgent changes to the costs and consumption of healthcare, it’s a system we can no longer afford. That is a bigger topic, and I’ll save it for another day.

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