This week, the administration released new final federal rules governing standards for Affordable Care Act (ACA) health insurance plans. The rules shift some standards from federal government oversight to states.

Main ACA rule changes to be implemented in 2019:

• State Flexibility in Designing Benchmark Plans - States will now have the following options for designing their benchmark health insurance plans: adopt another state's 2017 benchmark plan; replace one or more of its benefit categories with that of another state's; or completely build a new essential benefits package as long as the new plan is not too generous and is comparable to a "typical employer plan." CMS defines a typical employer plan as either one of the state's 10 base-benchmark plan options from the 2017 plan year, or one of the 5 largest group health insurance products by enrollment, not including self-insured plans.
• Essential Health Benefits - Although the new rules maintain the ACA’s 10 essential health benefits (EHB), they allow states to shift benefit coverage value across benefit categories, which means that plans can reduce covered benefits (i.e. treatments covered, etc.) if they expand benefit coverage in another EHB category.
• Network Adequacy - Insurance exchange network adequacy for the 39 states that rely on the federal exchange will be shifted from federal government responsibility to state responsibility.
• Individual Mandate Exemptions - Two new exemptions from the ACA’s individual mandate requirement are included in the new rules, one to permit exemptions for individuals living in areas with only one insurer and the other exemption for individuals opposed to abortion living in places where all plans cover abortions. These exemptions are available retroactively for 2017 and 2018.
• Flexibility in the MLR - States can request changes to the amount insurers must spend on medical claims, known as the medical loss ratio (MLR), if states can demonstrate that a lower MLR would help stabilize their markets. 
• Consumer Navigators - The rules may weaken the national network of consumer navigators that assist consumers with insurance options by eliminating the ACA’s requirement that every geographical area has at least two navigator groups, including at least one local group.

The ATS is particularly concerned about the impact of the changes to benchmark plan design and essential health benefit coverage. As the ATS stated in comments on the proposed rule in Nov. 2017, “Permitting significant variation in covered benefits, despite mandated categories of EHBs, will promote highly varied and potentially inadequate benchmark standards in states that may not include the full range of health care services that people with chronic respiratory and critical illnesses and sleep disorders need.”