The Biden administration plans to push states to boost oversight of the number of doctors, hospitals, and other health providers insurers cover in Obamacare plans, under rules proposed in November.<\/p>\n

The annual regulatory proposal, known as the payment parameters rule, also seeks to expand access to adult dental coverage in Affordable Care Act marketplaces and would require states to hold open enrollment periods for Obamacare plans at the same time of year. It\u2019s likely one of the last major ACA policy efforts of President Joe Biden\u2019s first term \u2014 and, if he loses reelection, could represent his final touches on the landmark health program created when he was vice president.<\/p>\n

Biden has been a staunch supporter of Obamacare and has taken steps<\/a> during his own first term in the White House to expand the program through rules and legislation, including measures that increased premium subsidies<\/a>. In part because of those subsidies, enrollment has increased steadily and hit records<\/a> under his watch.<\/p>\n

The proposal for 2025 would continue administration efforts to expand coverage, making it easier for states to offer plans that include adult dental care. The rules also set additional guardrails on the growing number of states that have chosen to run their own ACA marketplaces<\/a>.<\/p>\n

The rules need to be finalized in the spring and would affect plans starting in January 2025, not long before Inauguration Day.<\/p>\n

So expect some controversy.<\/p>\n

Already, the ACA has entered the political debate, with the current GOP front-runner, former President Donald Trump, taking to his Truth Social site on Thanksgiving weekend to call the failure of the GOP to repeal the ACA \u201c a low point for the Republican Party<\/a>.\u201d<\/p>\n

Trump also said he was \u201cseriously\u201d considering alternatives, which harked back to his presidency when he frequently promised<\/a> an Obamacare replacement was soon to be revealed. It never was.<\/p>\n

Biden quickly seized on Trump\u2019s comments, saying on Nov. 27<\/a> that \u201cmy predecessor has once again \u2014 God love him \u2014 called for cuts that could rip away health insurance for tens of millions of Americans.\u201d<\/p>\n

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Many of the changes made during Biden\u2019s term, especially to rules that spell out how the law is to be implemented, could be altered if a Republican wins the White House \u2014 just as occurred in the transition from the Obama administration to the Trump term and, again, when Biden took office.<\/p>\n
When Trump came into office, for example, he made a number of moves to roll back ACA rules set by the program\u2019s namesake, President Barack Obama, including sharply reducing funding<\/a> for enrollment assistance, shortening the annual sign-up period<\/a>, and allowing less expensive but less protective short-term plans<\/a> to cover longer periods of time. Biden\u2019s team, in turn, expanded funding for enrollment, added special enrollment periods, and has a proposal awaiting final approval that would restore restrictions on short-term plans<\/a>, which don\u2019t cover many of the benefits included in ACA plans and are often called \u201cjunk insurance\u201d by critics.<\/p>\n
\u201cIf the past is any guide, and the next administration is different, the first thing they will do is roll things back,\u201d said Sabrina Corlette, a research professor and co-director of the Center on Health Insurance Reforms at Georgetown University.<\/p>\n
Politics may be one reason the administration\u2019s latest proposal doesn\u2019t include larger changes to the ACA. Doing anything more aggressive in an election year \u201cmight disrupt a program that Biden fully supports,\u201d said Joseph Antos, senior fellow at the American Enterprise Institute, a right-leaning think tank.<\/p>\n
But the proposal from the Department of Health and Human Services does respond to concerns about \u201cnetwork adequacy,\u201d or whether insurers\u2019 doctor and hospital networks are large enough<\/a> to meet demand. The rules would require states<\/a> to set numerical standards, such as a maximum \u201ctime and distance\u201d that patients must travel to access in-network care, that are at least as rigorous as federal limits that kicked in this year.<\/p>\n
The proposal would affect the 18 states, plus the District of Columbia, that run their own<\/a> ACA marketplaces.<\/p>\n
While many of them already set some network parameters, the standards vary<\/a>. The administration\u2019s latest proposal notes that 25% of existing state rules fail to set any quantitative requirements, such as how long or far a patient might have to drive to find a participating provider, or the acceptable ratio of the number of enrollees in a plan to the number of covered medical providers.<\/p>\n
Requiring standards at least as tough as federal exchange rules across all states \u201cwould enhance consumer access to quality, affordable care,\u201d the document says.<\/p>\n
Some states \u201cmay not be doing enough to ensure compliance,\u201d said Corlette. \u201cStates will have to step up their game.\u201d<\/p>\n
States would also have to review insurer networks to see if they meet the standards before giving the go-ahead to sell their plans. While the federal marketplace will, beginning in 2025, require insurers to meet new rules aimed at limiting patients\u2019 wait times for appointments, especially for primary care and behavioral health, state marketplaces won\u2019t yet have to impose similar standards.<\/p>\n
More prescriptive state requirements for ACA insurers might draw some pushback during the public comment period for the rules, which runs through Jan. 8. They could also be a target for change if the GOP wins the White House, said Chris Condeluci, a health law attorney who worked as counsel to the Senate Finance Committee when the ACA was drafted.<\/p>\n
\u201cOn the one hand, it makes sense to have standardized rules so everyone is working off the same song sheet,\u201d said Condeluci. But he said there\u2019s support for the idea that state marketplaces were not \u201cto be nationally run or overly prescriptive from a federal government regulatory perspective.\u201d<\/p>\n
The HHS proposal also seeks to expand access to routine adult dental coverage by eliminating a prohibition against states including the care as an \u201cessential health benefit\u201d in their benchmark plans<\/a>. The rules would also standardize open enrollment periods across all states, requiring them to begin Nov. 1 and run through at least Jan. 15. Most states already do that, although Idaho\u2019s period currently begins Oct. 15 and ends Dec. 15, and New York\u2019s begins Nov. 16 and ends Jan. 31.<\/p>\n
The payment parameter notices, though dryly named, are a big deal not only for insurers, who plan their benefits and set their rates based in part on such rules, but also for consumers.<\/p>\n
The ACA marketplaces \u201ccover millions of people and it\u2019s very important to make sure they are working and people understand what they are buying,\u201d said Bethany Lilly, executive director of public policy at the Leukemia & Lymphoma Society.<\/p>\n
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