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Legislative & Regulatory Updates  
September 2021

 $452 million for State-Based Reinsurance
On Sept. 7, the Centers for Medicare and Medicaid Services announced the distribution of $452 million in “pass-through funding” for 13 states that have reinsurance programs created through approved Section 1332 waivers. State distributions will range from $2.5 million to $139 million, depending on the size of the state’s reinsurance program. Pennsylvania is set to receive nearly $28.6 million. These funds will be used to reimburse issuers for a portion of provider claims that would otherwise be paid by consumers and the federal government through higher premiums. States with reinsurance waivers have seen average individual market premium reductions of 3.75 percent to 41.17 percent. This stands in contrast to states without such programs.
Study: Majority of Large Insurers Have Ended COVID-19 Cost-Sharing Waivers
A recent study by the Kaiser Family Foundation found that 72 percent of large health plans no longer provide cost-sharing waivers for COVID-19-related care, and another 10 percent plan to phase out current waivers by the end of October. Nearly all plans surveyed said they will sunset such waivers by the end of the year.
Key House Committee Includes Permanent Expansion of Enhanced Advance Premium Tax Credits in Draft Bill
On Sept. 10, the U.S. House Ways and Means Committee released draft legislative language for its portion of the reconciliation bill (section-by-sectionpress release). The draft bill includes a provision to make permanent the enhanced advance premium tax credits that were included in the American Rescue Plan (ARP). ARP increased the generosity of subsidies for individuals with household incomes of 100 percent to 400 percent of the federal poverty level (FPL) and, for the first time, extended premium tax credits to those with incomes above 400 percent FPL. The draft reconciliation bill would also authorize $10 billion per year for 10 years for state reinsurance programs and to help close the coverage gap in states that have not expanded Medicaid. Including this expansion in the House Committee draft bill is a good first step; however, it is unclear whether the provision will remain in the bill that passes the full House and Senate. Moderate Democratic senators have pushed for a bill with a much smaller overall price tag, while progressives have a long list of priorities that a reduced-price measure is unlikely to accommodate. For the current bill to be passed, it must be supported by all 50 Democratic senators (plus Vice President Harris) and nearly all Democratic House members.
Regulators Delay Enforcing Key Elements of Price Transparency Rules
On Aug. 20, federal regulators issued sub-regulatory guidance, via Frequently Asked Questions, delaying the enforcement of several price transparency and surprise billing requirements included in the Transparency in Coverage (TiC) final rule and the Consolidated Appropriations Act of 2021 (CAA). Enforcement of several provisions is delayed to a specific, later date; others are delayed until the departments of Labor, Health and Human Services, and Treasury complete additional rulemaking. Here are some of the key changes:
  • Enforcement of the requirement that health plans/issuers disclose three machine-readable files for plan years beginning on or after Jan. 1, 2022, will be delayed to July 1, 2022, for in-network provider rates, out-of-network allowed amounts, and billed charges for covered items and services.
  • Enforcement of the requirement related to prescription drug pricing will be deferred pending future rulemaking as the departments address the interaction—including potentially duplicative and overlapping requirements—between the TiC final rule and the CAA.
  • The departments will defer to Jan. 1, 2023, enforcement of the CAA requirements related to providing consumers with a price comparison guide by phone and online. This is when a separate TiC provision will take effect, requiring plans/issuers to provide an internet-based, self-service price comparison tool (and one in paper form upon request) for 500 items and services. The tool and paper form must be available for all covered items and services by Jan. 1, 2024.
  • The departments do not intend to engage in future rulemaking with regard to the requirement that plans/issuers include applicable deductibles, out-of-pocket maximums, and a phone number and website for consumer assistance on plan ID cards for plan/policy years beginning on or after Jan. 1, 2022. They expect issuers to use a “good faith, reasonable interpretation of the law.” The departments have indicated that including the applicable deductible and out-of-pocket maximum on cards would constitute compliance.
  • The departments will defer enforcement of the “good faith estimate” requirement for insured individuals. It will also will defer enforcement of and undertake rulemaking for the “advanced Explanation of Benefits” requirement, but this will not happen until after the Jan. 1, 2022, effective date.
If you have any additional questions, please contact your UPMC Health Plan account manager.