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New Exchange Rule Biggest Pre-2016 Health Care Move

A sweeping new administration rule outlining how the health law’s insurance marketplaces will operate next year sweetens financial protections for insurers and clarifies the role of counselors known as “navigators” who help people enroll in medical plans.

The Department of Health and Human Services released the rule late last week in the effort to dramatically expand coverage under the health care overhaul. The comment period attracted a multipronged lobbying effort involving health plans, business groups and consumer advocates all eager to shape guidance for online insurance exchanges.

With Congress unlikely to enact major health care legislation before the next presidential election, the 436-page document delivers to some of the biggest health policy changes expected this year, affecting the federal health exchange handling enrollment for 36 states and 14 other online marketplaces that states created.

The rule “builds on the lessons learned from this year’s first open enrollment period and provides the certainty stakeholders need in order to prepare for next year’s open enrollment period,” Mandy Cohen, director of the Center for Consumer Information and Insurance Oversight, wrote in a blog post.

The final version of the rule, subject of a detailed three-part analysis by CQ HealthBeat, brought mixed results to almost every interested party.

Health insurers seeking financial compensation for the rocky rollout of the exchanges last October won federal payments to offset the expense of complicated medical cases costing more than $45,000, which was higher than the administration suggested in March. But the administration also rejected a bid from plans such as the Blue Cross and Blue Shield Association to further tweak a formula that caps insurers’ losses and profits. The final version only allowed the insurers to collect profits 2 percentage points above what the administration first said it would allow.

The rule strengthened the role of navigators and other enrollment assisters by declaring that state laws limiting the range of their assistance are a violation of the 2010 federal health care law.

Federal regulators also clarified what would happen if counselors inappropriately released consumers’ personal information. The agency stated that the maximum amount offenders could be dunned is $100 per day per violator, and that the government could set lower fines. It also blocked the Department of Health and Human Services inspector general from imposing fines and stated assisters could not face civil penalties under both the health care law and other federal laws.

Consumer groups won another victory when HHS accepted a proposal from the advocacy group Families USA to publicly release full survey results from consumers that rate health plans. The final rule clarifies that HHS will publicly post full survey results for marketplaces run by the federal government in 2016 instead of just a subset of results that would be included in a plan’s quality rating.

The Small Business Majority, an ally of the Obama administration, criticized another section of the rule that allows states to delay for one year a requirement that would allow small business workers to be able to choose which health plan they want to enroll in. Currently small business owners select insurance packages for their workers.

An opt-out could put small businesses at a competitive disadvantage to big employers that are able to offer a choice of plans to their employees,” said John Arensmeyer, founder and CEO of the Small Business Majority. He added that the group believes “delaying this rule violates the law and the spirit of the Affordable Care Act.”