Potential changes to the Medicaid managed care Mega-Reg announced (November).  Comments are due mid January. CMS went with a revise (vs replace) approach.  Main thrust of revision is to tighten rules for federal match and to relax potentially onerous requirements around network adequacy and access standards.  Pass through payments compliance is given a 3 year transition period. CMS has proposed to move back to allowing rate-cert at the range level (the 2016 reg required all individual rate cells to be certified).  There are less documentation requirements for rate cert. States  have more flexibility in the required implementation of the Quality Rating System (QRS).  No changes to MLR  terms were included in the revision.

New guidance on 1332 waivers would allow important changes to richness of benefit for exchange plans (October).  HHS released guidance for  exchange based plans that would favor private plans (seen by some as a pre-emptive strike for Medicaid buy-in options expected in 2019), offer plans that don’t meet the essential benefits requirements as long as one ACA-compliant plan is on the exchange,  and will allow members to use subsidies to purchase plans that are not ACA-compliant.

A Federal judge has ruled that ACA is unconstitutional (December). A 5th circuit judge has ruled that since the tax supporting ACA was reduced to zero last year, and the individual mandate struck down, the entire of ACA is now untenable.  The legal reasoning is that the law is predicated on Congressional taxing authority. Most analysts expect it to be overturned on appeal, but this may be the strongest threat to ACA to date.

CMS approved KY work requirements waiver for 2nd time. After a lawsuit that alleged CMS did not conduct proper analysis on the impact, CMS did a re-do and approved it again in November.  Another lawsuit is expected, but most likely plans in KY will have to implement the new requirements in 2019.

Proposed  changes to the Public Charge Rule could impact enrollment numbers (October). CMS has proposed including other public assistance benefits in the consideration of whether  an immigrant applying for admission  would be expected to become a public charge.  Most analysts predict the new rule would reduce approved applications. Medicaid markets with high immigrant enrollment could be impacted.