July 12, 2017

Randy Pate, Deputy Administrator and Director
Center for Consumer Information and Insurance Oversight
Centers for Medicare & Medicaid Services
Department of Health & Human Services

Submitted electronically via: www.regulations.gov
RE: CMS-9928-NC

Dear Director Pate:

The Association for Community Affiliated Plans (ACAP) respectfully submits comments in response to the Request for Information on Reducing Regulatory Burdens Imposed by the Patient Protection and Affordable Care Act & Improving Healthcare Choices to Empower Patients.

ACAP is an association of 60 not-for-profit and community-based Safety Net Health Plans (SNHPs) located in 29 states. Our member plans provide coverage to more than 20 million individuals enrolled in Medicaid, the Children’s Health Insurance Program (CHIP) and Medicare Special Needs Plans for dually-eligible individuals, including over 700,000 Marketplace enrollees. Nationally, Safety Net Health Plans serve almost half of all Medicaid managed care enrollees. Seventeen of ACAP’s Safety Net Health Plan members offer qualified health plans (QHPs) in the Marketplaces in 2017.

Summary of ACAP’s Comments
ACAP has chosen to respond to a subset of proposals in the proposed Marketplace Stabilization rule that are particularly relevant to Safety Net Health Plans (SNHPs), and we further wish to draw attention to a particular subset of our comments. ACAP appreciates the Administration’s recognition of the need for improved market stability during a time of political uncertainty in the Legislative Branch. ACAP’s comments are focused on ensuring market stability for SNHPs and the consumers they serve. Specifically, our comments are focused so as not to place undue burden or harm on consumers, in particular the low-income and vulnerable populations that are traditionally served by SNHPs.

ACAP would like to emphasize that the comments herein support SNHPs in their efforts to serve their communities, which they have experience with given their historical expertise in serving Medicaid enrollees. We believe there is a careful balance that must be struck in order to support issuers in the Marketplace while at the same time not instituting policies that would have a deleterious impact on consumers. We also support, where possible, an alignment between state and federal requirements, such as for claims and appeals, application filings, and other templates. We appreciate recent changes already made by this Administration to return network adequacy monitoring to the states.

ACAP’s comments generally address questions 2 and 3 in the RFI—how to stabilize the individual market and make coverage affordable for consumers and small businesses. We have not separated out our comments to respond to one question or the other, as we believe the two are inherently connected and that stabilizing the individual market will bring about improved affordability. Our comments address the following recommendations:

Continue CSR Payments: ACAP believes the single most important action the Administration can take to stabilize the Marketplace is to guarantee continued payment of CSR subsidies.
Enforce the Individual Mandate: ACAP urges the Administration to commit to continued enforcement of the individual mandate as the best way to encourage uninsured individuals to purchase coverage, thereby improving the risk pool and improving affordability for consumers.
Restrict Short-Term Limited Duration & Non-Compliant Plans: ACAP urges CMS to limit the availability of non-compliant plans, including short-term, limited duration plans.
Improve MLR Calculations: ACAP urges CMS to calculate MLR across all lines of business and urges technical changes to the MLR calculation to account for health promotion and fraud prevention activities.
Develop Plan Suppression Guidelines for SNHPs Based on RBC: ACAP urges CMS to establish a formal procedure for plan suppression based on risk based capital constraints of SNHPs.
Streamline Patient Safety Requirements: ACAP urges CMS to streamline burdensome verification requirements on issuers for hospital compliance with patient safety standards.
Study Utilization of SEPs & SEP Pre-enrollment Verification: ACAP urges CMS to study special enrollment period utilization, particularly in the context of the impact of pre-enrollment verification requirements.
Streamline Risk Adjustment Transfer Process: ACAP urges CMS to reduce the burden of the risk adjustment process, such as by providing earlier and more frequent interim transfer estimates.

View the expanded comments »