Grace Period Payment Threshold
If an enrollee has not made their premium payments in full, the ACA provides for a grace period which is a certain period (1-3 months) where premiums can be made to keep enrollment. If payments are not made by the end of the grace period, enrollment would be terminated. However, some enrollees receive APTC credits that pay a significant portion of their premiums. In this case, it may not be beneficial for the enrollee or the issuer to cancel enrollment prematurely. A threshold is already in effect whereby if 95% of net premiums are paid, issuers would not need to institute a grace period.
HHS also proposed to allow a threshold based on a gross premium owed by the enrollee, rather than net premium with a 99% threshold. This was finalized at 98% gross premium threshold.
An alternative fixed dollar amount is proposed to allow issuers to use a fixed dollar payment threshold so issuers would not be required to trigger grace period or terminated enrollees for non-payment. [28] Suggested at $5 of less, inflation adjusted but CMS is soliciting comments on the level. The fixed dollar would have to be applied uniformly. This was finalized, but increased to a fixed dollar threshold of $10 adjusted forward for inflation, using the National Health Expenditure Forecast published annually by CMS’ Office of the Actuary.
A note was provided that some payment should always be required to effectuate enrollment, aka a binder payment, to show that a consumer desires coverage.
Open Enrollment Data
In an effort to increase transparency, HHS anticipate “publicly releasing the Exchanges annual State-based Marketplace Annual Reporting Tools (SMARTs), programmatic and financial audits, Blueprint applications, and additional data points in the Open Enrollment (OE) Data Reports.”[29] They anticipate beginning with the plan year 2023 SMART. Upon finalizing the proposal, HHS indicated they would NOT be releasing the SMARTs, for various reasons including that the SMARTs contain non-public operational and business processes employed by Exchanges to maintain program integrity and combat fraud, such as procedures used for verifying consumer information.
HHS also anticipate expanding Open Enrollment data by publishing additional metrics related to State Exchange operations and functionality. This information is already collected and does not reflect additional reporting. It includes: State Exchange spending on outreach (including Navigators), eligibility and enrollment policies and processes, plan certification requirements, and operational performance data, including Open Enrollment call center metrics (call center volume, average wait time, average call abandonment rate) and website visits and visitors. HHS finalized the release of the following:
- Exchange actual expenditures on Navigator program, total allocation and per grantee,
- Exchange call center metrics during Open Enrollment:
- Total number of incoming calls received by the call center.
- The average wait time for each incoming call to the call center.
- The number of incoming calls terminated while waiting to speak to a call center representative.
- The average amount of time spent by call center representative on each individual call.
- Exchange website (eligibility and enrollment application and/or consumer) visitors during Open Enrollment:
- Number of website and mobile application visits.
- Number of unique visitors requesting the website and mobile application.
[28] C. Part 155—Exchange Establishment Standards and Other Related Standards – 5. Establishment of Optional Fixed- Dollar Premium Payment Threshold and Total Premium Threshold (§155.400(g))
[29] C. Part 155—Exchange Establishment Standards and Other Related Standards – 9. General Program Integrity and Oversight Requirements (§155.1200)