Entries in Innovation (2)


ACA Exchange 2020 Final Rule Changes and Survey of Exchange Health Plan Participation and Expectations

By Clive Riddle, May 31, 2019 

Last month CMS issued their final rule with ACA benefit and payment parameters for 2020. Their changes for 2020 included: 

  • The method for calculation of premium assistance for lower-income enrollees (projected to lower the total amount of financial assistance provided by $900 million, when compared with 2019, and result in 100,000 fewer exchange enrollees in 2020.)
  • Allowing plans to make mid-year changes to their drug formularies
  • Allowing plans to implement cost-sharing requirements if enrollees choose a brand-name drug when a medically appropriate generic version of the drug is available (even when out-of-pocket spending maximum is reached)
  • Allowing plans to implement copayment accumulator programs for prescription drugs
  • Lowering user fees for the 2020 coverage year by half a percentage point
  • Increases maximum out-of-pocket spending limits by 3.2%, from $7,900 to $8,150 for individual plans and from $15,800 to $16,300 for family plans      


How will these changes, and overall market forces, impact health plan participation in the ACA exchanges for 2020? eHealth has just released survey results from 17 plans that collectively cover 80 million lives that participate in ACA exchanges, that found “more than twice as many insurers intend to increase plan offerings for 2020 as compared with 2019, with premiums holding fairly steady.”



Here’s some of their detailed findings: 

  • 45% intend to add to the number of ACA plans they'll offer in 2020, compared to 21% who did so for the 2019 plan year
  • 42% expect to raise premiums between 5 and 10 percent over 2019 rates. 33% do not expect to make any noteworthy changes to premiums, while 23% expect to reduce monthly premiums by 5 percent or more.
  • 69% said that sales during the last open enrollment period were within 10 percent of their expectations. 15% reported that sales outpaced expectations by 10 to 15 percent, while another 15% of said sales were 10 percent or more below expectations.
  • 71% said they are paying attention to public discussions about "Medicare for all" but don't expect major changes, compared to 67% in 2018




CBO: Coverage by Oration

by Clive Riddle, May 3, 2019

 The Congressional Budget Office has been quite busy as of late, preparing reports that can serve as reference resources in response to Orators residing in Congress, the White House and the campaign trail, that are espousing healthcare coverage policy proposals, whether those proposals being orated involve Medicare for All, Medicare for Some, Death to the ACA, or other such schemes.

On May 1st, the CBO released a 34-page report:  Key Design Components and Considerations for Establishing a Single-Payer Health Care System, serving as a roadmap that “describes the primary features of single-payer systems, and it discusses some of the design considerations and choices that policymakers will face in developing proposals for establishing such a system in the United States.”

The report is organized by these categories of components and design considerations: 

  • How would the government administer a single-payer health plan?
  • Who would be eligible for the plan, and what benefits would it cover?
  • What cost sharing, if any, would the plan require?
  • What role, if any, would private insurance and other public programs have?
  • Which providers would be allowed to participate, and who would own the hospitals and employ the providers?
  • How would the single-payer system set provider payment rates and
  • purchase prescription drugs?
  • How would the single-payer system contain health care costs?
  • How would the system be financed? 

In May 2nd, the CBO released a 42-page report: Federal Subsidies for Health Insurance Coverage for People Under Age 65: 2019 to 2029, which “project that federal subsidies, taxes, and penalties associated with health insurance coverage for people under age 65 will result in a net subsidy from the federal government of $737 billion in 2019 and $1.3 trillion in 2029.”

 The report tells us that:

  • Between 240- 242 million people are projected to have health insurance each month during 2019-2029. The number of uninsured is projected to rise from 30 million in 2019 to 35 million in 2029.
  • Net federal subsidies for insured people will total $737 billion in 2019 and $1.3 trillion in 2029.
  • Medicaid and CHIP account for 40 - 45 percent of the federal subsidies, Medicare accounts for about 10 percent, and subsidies for ACA marketplace coverage account for less than 10 percent.

On April 18th the CBO provided a blog post: CBO Releases Four Products Explaining How Its New Health Insurance Simulation Model Works that describes how they generate estimates of health insurance coverage and premiums for the population under age 65, such as for the May 2md Federal Subsidies report.


 Also on April 18th, the CBO released an 11-page report:  Health Insurance Coverage for People Under Age 65:  Definitions and Estimates for 2015 to 2018 that “explains how CBO defines health insurance coverage, describes how CBO combines data from various sources to produce estimates of different types of coverage in past years, and shows such estimates for the years 2015 to 2018.” 


The report:  

  • Describes how CBO defines health insurance coverage (private and public) for people under 65 who are not institutionalized and who are not members of the active-duty military;
  • Describes the individual data sources CBO uses to compile preliminary estimates of historical outcomes, and the limitations of those sources; and
  • Compares preliminary estimates of historical outcomes with CBO’s integrated estimates of coverage (that are consistent with each other and that sum to accurately depict the total population) for 2015 to 2018.