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This annual proposed rule would set forth payment parameters and provisions related to the risk adjustment and risk adjustment data validation programs; cost-sharing parameters; and user fees for issuers offering plans on Federally-facilitated Exchanges and State-based Exchanges using the Federal platform. It would also provide additional standards for several other Affordable Care Act programs.

Statement of Need:

The provisions in this proposed rule aim to promote greater stability and affordability in health insurance markets. This rule proposes standards related to the risk adjustment program for the 2021 benefit year, clarifications and improvements to the risk adjustment data validation program, as well as certain modifications that will promote transparency, innovation in the private sector, reduce burden on stakeholders, and improve program integrity. 

Summary of the Legal Basis:

This rule addresses multiple provisions in title I of the Patient Protection and Affordable Care Act (PPACA).

Alternatives:

In developing the policies contained in this proposed rule, we considered numerous alternatives to the presented proposals; however, we believe the provisions are necessary for the upcoming benefit year.  Key regulatory alternatives will be included in the proposed rule.

Anticipated Costs and Benefits:

The rule proposes a minimal number of changes to provide states and health insurance issuers a more stable and predictable regulatory framework, while ensuring taxpayer money is spent appropriately and that states have flexibility and control over their insurance markets. The proposals would reduce regulatory burden, reduce administrative costs for issuers and states, and would lower net premiums for consumers. Through the reduction in financial uncertainty for issuers and increased affordability for consumers, these provisions are expected to increase access to affordable health coverage. Although there is still some uncertainty regarding the net effect on premiums, we anticipate that the provisions of this proposed rule would improve affordability. We therefore expect that these proposals would help further HHS’s goal of ensuring that all consumers have access to quality and affordable health care and are able to make informed choices, that the insurance market offers choices, and that states have more control and flexibility over the operation and establishment of Exchanges.  As we move toward publication, estimates of costs and benefits will be included in the proposed rule.

Risks:

If this regulation is not published, important updates applicable to the 2021 benefit year would not be available to consumers, providers, employers, health plans, and advocacy groups.