AHA presses CMS to do more on cost sharing, junk plans
The group urged CMS to consider other coverage gaps that subject patients to unaffordable cost sharing and address them in its rulemaking.
Photo: Jose Luis Pelaez Inc/Getty Images
The American Hospital Association has lauded efforts by the Centers for Medicare and Medicaid Services to limit short-term "junk" health plans, but is pressing the agency to do more on the issue of unaffordable cost sharing, "even in ACA compliant health plans," the AHA wrote in a letter to CMS this week.
In its message to the government agency, the AHA said it was "deeply concerned" with both the amount and the complexity of patient cost sharing. To that end, it urged CMS to consider other gaps in coverage that subject patients to unaffordable cost sharing and address them in future rulemaking.
"For example, we increasingly are hearing reports of commercial health insurers implementing convoluted policies – such as mid-year coverage changes, excessive application of prior authorization, and complex cost-sharing and network structures – that leave patients unsure of whether their care will be covered," the AHA wrote.
WHAT'S THE IMPACT
One of the most concerning trends from the AHA's perspective is the growth in adoption of high-deductible health plans, as well as the deductible amounts. According to the group, these types of products are often marketed – inaccurately – as more cost-effective options for lower income individuals and families. As a result, the AHA said that many people only realize when they need care that their health coverage does not cover as much as they thought, subjecting them to unexpected medical bills.
"This can create undo financial and emotional stress and contributes to medical debt," the AHA wrote. "We urge the agency to take steps to simplify cost-sharing structures and reduce the amounts owed out of pocket."
When it came to short-term, limited-duration plans – so-called "junk" plans – the AHA said it appreciated CMS' proposal to limit those types of plans and require clear, consumer-friendly notices in their marketing materials. It concurred with CMS' assessment that these plans provide inadequate access to care and can subject patients to greater out-of-pocket spending when illness or injury occur.
Patients enrolled in those plans often find themselves surprised to be without coverage for emergency services, cancer care and hospital stays, among other services, due to misleading marketing practices, the AHA said.
Limiting those types of plans, the group contended, creates a much clearer distinction between these products and comprehensive coverage.
"However, we encourage CMS to ensure upon finalizing this proposal that the changes do not impede health insurance coverage innovations that could provide appropriate coverage through non-traditional structures," the AHA said.
The organization also supports CMS' proposal to require a straightforward notice in these products' marketing materials stating they do not provide comprehensive coverage, and offering information on how to purchase comprehensive coverage on healthcare.gov.
THE LARGER TREND
In July, the Department of Health and Human Services pledged to protect consumers from junk plans, surprise medical bills and excess costs that lead to medical debt.
According to the Leukemia and Lymphoma Society, patients with pre-existing conditions are often saddled with low-quality policies that are exempt from some consumer protections – i.e., junk plans.
HHS and the Departments of Labor and Treasury are attempting to tackle the issue by issuing proposed rules aimed at distinguishing short-term, limited-duration insurance (STLDI) and fixed indemnity insurance (plans that pay a predetermined fixed amount for a health-related event, regardless of expenses incurred) from comprehensive coverage.
The proposed rule, among other policies, would amend the federal definition of STLDI to ensure these "short-term" plans are truly short-term, and are used to fill temporary gaps in comprehensive coverage. It would also require STLDI and fixed indemnity excepted benefits coverage to make clearer to consumers the differences between these products and comprehensive coverage, including what is covered and how much is covered.
A little over a year ago, in April 2022, House Democrats called on HHS to end junk plans, imploring Secretary Xavier Becerra to reverse the final rule issued by the Trump administration that expanded the short-term, limited duration plans and restore them to their intended purpose as short-duration, temporary coverage.
The Obama administration had limited the duration of STLDI plans to less than three months. However, in 2018 the Trump administration issued a final rule that allowed individuals to purchase STLDI plans for up to a year, with up to three years of renewable coverage.
One analysis of STLDI plans found that 43% of plans surveyed failed to cover mental health services, 71% of plans did not cover outpatient prescription drugs, and no plans covered maternity care.
Twitter: @JELagasse
Email the writer: Jeff.Lagasse@himssmedia.com
