If Only There Were Cliff Notes on Proposed ACA Regs

As the October 31st deadline looms for groups that want to comment on the three proposed rules relating to the eligibility and enrollment of individuals into health coverage under the Affordable Care Act, many groups may wish “Cliff Notes” were available to help them sort through all the issues and the potential impact on children and families.  Today is their lucky day as CCF has released a summary of the issues and proposed comments.  Groups are welcome to use CCF’s “Cliff Notes” in whole or in part, summarized, paraphrased or edited in whatever form they see fit.

These proposed rules are extremely important to achieving the goal of ensuring that all eligible people secure health care coverage so we strongly encourage groups to take advantage of the free Cliff Notes and get their comments into HHS by October 31.  If you are able to comment on only a few key issues, we encourage you to consider commenting on the following issues of particular importance to children and families: 

  • Provide stronger federal oversight.  The proposed Medicaid and Exchange rules outline an ambitious vision for simple, unified eligibility determination procedures, but provide little or no detail on how HHS will ensure that states follow the proposed procedures.  To make the new eligibility and enrollment systems work for families, it is critical that states adhere to the federal requirements.
  • Retain and strengthen simplifications to the application and renewal process for Medicaid and CHIP. For children and families, a key measure of the success of the ACA will be whether it promotes the enrollment of the significant numbers of currently eligible but uninsured children in Medicaid or CHIP.  The proposed rule would go a long way toward increasing such enrollment by requiring states to use a single, streamlined application for all affordability programs that can be submitted online, over the phone, through the mail, or in-person; to rely on electronic verification of data to the maximum extent practicable; and to adopt streamlined renewal procedures.
  • Provide stronger and more clear guidance on the circumstances under which states must use electronic verification of data.  Under the ACA, States must rely on electronic verification of data to the “maximum extent practicable” when evaluating eligibility.  In both the Medicaid and Exchange eligibility rules, it is proposed that states must verify eligibility for coverage by first gathering data from electronic sources. States can request additional documentation from applicants only if no electronic data are available or the data are “not reasonably compatible” with stated circumstances.  If implemented as intended, these provisions would mean that people no longer will be unnecessarily required to bring in, mail, or fax copies of their pay stubs and other documents.  The proposed rules, however, provide no detail on what constitutes “reasonably compatible” data, opening up the prospect that states reluctant to enroll people in coverage will adopt a state-defined standard that discourages enrollment in coverage.
  • Adopt a family-based affordability test that does not discriminate against married couples and families with children. We are deeply concerned that the proposed Treasury rule excludes families from advance premium tax credits if they have access to employer-based coverage even when such coverage would cost more than 9.5 percent of income.  The issue arises in 1.36B-2(c)(3)(v), which defines “affordable” employer-based coverage, including for a family, as an offer of self-only coverage that costs less than 9.5 percent of household income.  If included in the final rule, this policy would cause millions of families to face the unreasonable expectation that they can purchase coverage that consumes more than 9.5 percent of their income.  In many instances, children in these families may be able to secure coverage through Medicaid and CHIP while there is a strong maintenance-of-effort law for Medicaid and CHIP in place.  However, not all children in affected families will have an alternative and even those who do may have parents who remain uninsured. 
  • Address the issue of families facing a “double premium hit” for their children. The proposed rules will leave many families with children facing multiple, additive obligations when it comes to paying insurance premiums if they happen to have a child eligible for CHIP (or, in some circumstances where premiums apply, Medicaid).  These families must pay to purchase full family-based coverage on the Exchange and CHIP premiums for their children. The amount they are expected to pay for their Exchange coverage is not adjusted in any way to reflect that they also have premium obligations for CHIP for their children.
  • Eliminate waiting periods in CHIP.  The proposed Medicaid rule fails to address the issue of waiting periods in CHIP (i.e., minimum lengths of time during which children must be uninsured before they can enroll in coverage).  In general, waiting periods no longer make sense in a post-ACA universe in which everyone is expected to enroll in coverage and, indeed, can face penalties for failing to do so.
  • Ensure reconciliation rules accommodate changing family circumstances.  The proposed Treasury rule on reconciling the premium tax credit with advance credit payments fails to appropriately take into account situations of families experiencing major changes in household income in the course of the year.  We are very concerned that this omission will lower participation of healthier-than average people in the Exchanges, drive up premium costs in the Exchanges, and undermine support for the ACA.

For a more thorough analysis please see CCF Memo:  Major Implications for Children and Families of the Proposed Affordable Care Act Rules on Eligibility and Enrollment Systems. Full comments from a group of national organizations are available on Medicaid, Exchanges and Premium Tax Credits.

Cathy Hope
Cathy Hope is the Communications Director at the Center for Children and Families