The Centers for Medicare & Medicaid Services (CMS) recently issued a proposed rule, “Patient Protection and Affordable Care Act: Exchange Program Integrity,” to ensure that people are accurately determined eligible for premium subsidies they receive through the Exchange. But the proposal also calls for insurers to send a separate bill and collect separate payments for the tiny portion of the consumer’s premium that covers certain abortion services prohibited from using public funding. CMS has also issued two final rules that expands religious and moral exemptions for providing contraceptives. RISE looks at the key takeaways for health plans.

A new federal proposed rule aims to ensure that premium tax credits only go to consumers who are eligible for them. This portion of the proposed rule is mainly technical, such as requiring states to compare their marketplace enrollment with other government programs, like Medicaid and Medicare. CMS also plans to expand the rules that allow enrollees who are not receiving subsidies to have the marketplace automatically terminate their coverage when they enroll in Medicare.

Beginning with the 2020 plan year, consumers would be able to voluntarily terminate their qualified health plan coverage if they are also enrolled in Medicare. The Department of Health and Human Services endorses this proposal because consumers are aging into Medicare, but failing to terminate their quality health plan coverage, which could create a tax liability for the Advanced Premium Tax Credit.

But the proposal also includes changes that could significantly impact qualified health plans that cover abortion services. The rule contains changes to the way the health plans must offer, and consumers must pay for, abortion services under the Affordable Care Act (ACA).

Changes to billing and payment requirements

The Hyde amendment allows federal funds to be used for abortion services only in the cases of rape, incest, or if a woman suffers from a life-threatening physical disorder, physical injury, or physical illness that would, as certified by a physician, place the woman in danger of death unless an abortion is performed.

The Hyde Amendment doesn’t allow the use of federal funds for abortion coverage in instances beyond those circumstances (non-Hyde abortion coverage).

Although the ACA does allow qualified health plans to cover abortion services, insurers cannot use exchange subsidies to pay for non-Hyde abortion services. If an insurer does provide coverage for non-Hyde abortions, they must separately collect and segregate funds for these services in a separate account that is designated for abortion. This payment must be at least $1 per enrollee per month.

Under the latest proposal, CMS would require insurers to bill for this portion of the premium separately to better meet what it describes as the Congressional intent to bill separately for two distinct payments, one for non-Hyde abortion services, and one for all other services covered under the policy. Essentially this means that in addition to the monthly premium bills that they send to consumers, health plans would have to issue separate bills each month to cover that portion of the premium (a minimum of $1 a month). This means a separate bill in a separate mailing with separate postage. If a qualified health plan sends bills electronically, CMS proposes that consumers receive the bills in separate emails.

Bottom line: This could become a huge operational burden for insurers, making it difficult for them to cover non-Hyde abortions.  Indeed, in his Twitter feed, former Acting CMS Administrator Andy Slavitt said the move is “being done to show that taxpayer funds aren’t being used but likely creates an incentive not to cover abortion services.”

Final rules expand religious, moral exemptions for providing contraceptive coverage

CMS has also issued two final rules that expand religious and moral exemptions for providing contraceptives in health plans.

These rules primarily finalize a controversial interim rule released last year that led to ongoing legal challenges. In a fact sheet, the administration said it received more than 100,000 public comment submissions after the interim rule was released.

The rules essentially allow some employers to deny insurance coverage of birth control for religious or moral reasons.

The religious exemption final rule allows organizations and individuals to opt out of the contraceptive coverage based on their sincerely held religious beliefs. The moral exemption final rule allows nonprofit organizations, small businesses and individuals that have non-religious moral opposition to the contraceptive mandate protections to also opt out of the coverage.

The administration said in the fact sheet that the exemptions will affect no more than 200 employers with religious or moral objections and of those organizations, many have already been allowed to not cover contraceptives under the previous rules or permanent court injunctions. But it also estimates the exemptions will affect the coverage of roughly 6,400 women, which it describes as a small fraction of the 165 million women in the United States.

Bottom line: This should not be a huge burden for insurers because they will just apply a process they should already have in place to potentially more employers. It also shouldn’t dramatically impact premiums because the cost of contraceptive coverage as part of a premium is very small.