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February 19, 2019
Seema Verma
Administrator
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Hubert H. Humphrey Building
200 Independence Avenue, SW
Washington, DC 20201
RE: CMS-9926-P, Patient Protection and
Affordable Care Act; HHS Notice of Benefit and Payment
Parameters for 2020
Dear Administrator Verma:
The undersigned organizations represent people with cancer
who need adequate and affordable insurance to ensure
access to quality and timely cancer care. We are
writing to share our concerns about provisions of the
Notice of Benefit and Payment Parameters for 2020 that may
threaten cancer patients’ access to quality care. We
urge reconsideration of certain provisions of the
proposal.
Automatic Re-Enrollment
The Centers for Medicare & Medicaid Services (CMS)
does not propose ending automatic re-enrollment in 2020
but asks for comment on terminating the policy of
automatic re-enrollment of consumers in exchange plans,
beginning with plan year 2021. We urge the
agency to reject any movement away from automatic
enrollment. As the agency states, automatic
re-enrollment makes enrolling in health insurance more
convenient for the consumer and is consistent with private
insurance practices. In our experience, the
assurance that consumers will be enrolled in a plan at the
end of open enrollment affords a protection that is
important to cancer patients.
Some of our organizations offer assistance to patients as
they evaluate their plan options, to help those patients
select coverage adequate for their cancer care
needs. We know firsthand that this selection process
is not easy and materials about plan options are not
always useful. As the agency notes, enrollment
materials should be designed to be consumer-friendly so
that consumers understand the value of the plans they are
considering. CMS signals a commitment to assisting
with that design. We also support the efforts
of CMS to “explore ways to increase the interoperability
of patient-mediated health care data across health care
programs, including in coverage purchased through the
Exchanges.” Even if there is success in
improving the materials available to consumers to support
solid plan selection, we do not think that success would
justify elimination of automatic re-enrollment.
The agency suggests that automatic re-enrollment makes
consumers less aware of their plan options, blocks action
to update their coverage and premium tax credit
eligibility, and leads to unrecoverable federal spending
if premium assistance is miscalculated. We agree
that all these shortcomings of the enrollment process
should be addressed. However, we do not believe that
eliminating automatic re-enrollment would solve these
problems.
The Role of Navigators
The proposed rule would make the provision of
post-enrollment assistance by navigators in the federally
facilitated exchanges an optional activity. We
understand that reductions in funding for navigators have
placed strains on the system. However, we believe
the solution is to provide adequate resources for
navigators instead of reconsidering the allowable
activities of navigators.
In our experience, cancer patients face significant
difficulties in understanding their health insurance
coverage and how to use it most effectively to pay for
quality cancer care. Cancer patients confront
challenges related to network limits, coverage and payment
standards for different elements of cancer care, and
formulary issues. All these issues may affect the
choices and options for care available to them.
Cancer care is typically complex and interdisciplinary,
and patients benefit from assistance in utilizing their
insurance to pay for their care. We urge a
continuation of the requirement that navigators provide
post-enrollment assistance.
Mid-Year Formulary Changes
CMS proposes to permit plans to make mid-year formulary
changes to introduce new generic drugs to their
formularies. Plans would be permitted to move the
brand name drug for which a new generic drug is added to
the formulary to a higher tier or drop the brand name drug
from the formulary. Plan enrollees would be given a
60-day notice regarding mid-year formulary changes.
Mid-year formulary changes may put cancer patients at risk
of disruption of their treatment plan and loss of access
to the drugs recommended by their care team. We
recommend that several patient protections be incorporated
into this proposal. Patients who are utilizing a
brand name drug for which a generic is introduced should
not be required to switch to the generic drug without the
recommendation of their care team. In connection
with other drug pricing proposals discussed or advanced by
this administration, this protection has been
recommended. We urge that it be included in this
proposal. The plan should also provide at least 90
and preferably 120 days of notice of a formulary
change. For patients already utilizing a brand name
drug, this would be a lesser protection than permitting
them to remain on current therapy. However, this
90-day or 120-day timeline should be included for all
consumers, to permit them to plan their treatment with
full knowledge of the current formulary. There must
also be an efficient exceptions process, in the situations
where a health care provider believes that the brand name
should be utilized in place of the generic added to the
formulary.
Calculation of Premium Adjustment Factor
The agency has proposed to change the manner in which the
premium adjustment factor is calculated. Under the
agency proposal, National Health Expenditure Account
(NHEA) estimates for all types of health insurance (except
Medigap plans) would be included in the calculation.
This contrasts to the premium adjustment factor
calculation of past years, which has been based on
employer-sponsored insurance rates. The agency
suggests that the change in the calculation will more
closely reflect the premium trends for all individuals in
the private insurance market since 2013.
It seems that the agency is making this change in the
calculation to save federal funds and because it has
determined to forgo policy changes to address so-called
silver loading in 2020. We are concerned about the
proposed calculation of premium adjustment factor, because
of its significant financial effects on consumers and
because it would result in a loss of insurance
coverage. CMS details the impact of the proposed
changes in the premium adjustment factor calculation,
including: 1) a higher maximum annual limitation on
cost-sharing, 2) higher employer shared responsibility
payment amounts, and 3) fewer employed individuals
qualifying for the Advanced Premium Tax Credit, or
APTC. In addition, CMS anticipates that the
Department of the Treasury and the Internal Revenue
Services will adopt the same premium measure, which would
result in a decrease in the premium tax credit for which
consumers would qualify and increase the contribution that
consumers must make. The agency also predicts that
the premium adjustment factor calculation will result in
premium increases for exchange plans, in turn causing
healthier enrollees not to purchase insurance on the
exchanges.
Although the agency goal of reducing federal expenditures
may be realized through this revised premium adjustment
factor calculation, the corresponding impact on consumers
will be significant and negative, as they face higher
maximum cost-sharing amounts and higher premiums, in some
cases resulting in decisions to forgo coverage.
We understand that the agency has considered a change to
calculating the premium adjustment factor in the past but
has rejected the change. We urge the agency to
follow this example for 2020, by retaining the current
methodology for calculation of premium adjustment factor
and thereby retaining important protections for consumers.
If the change in the calculation is an indirect way of
addressing silver loading, we recommend instead that the
agency pursue a solution to payment of cost-sharing
reductions and then address silver loading. We
object to the change in the premium adjustment factor
calculation because of the adverse effects of the change
on consumers.
We appreciate the opportunity to comment on the proposed
Notice of Benefit and Payment Parameters for 2020.
We look forward to changes in the final notice, so that it
more clearly reflects the needs of consumers who are
seeking insurance coverage that protects their access to
quality health care.
Sincerely,
Cancer Leadership Council
CancerCare
Cancer Support Community
The Children's Cause for Cancer Advocacy
Fight Colorectal Cancer
International Myeloma Foundation
Leukemia & Lymphoma Society
LUNGevity Foundation
Lymphoma Research Foundation
National Coalition for Cancer Survivorship
Ovarian Cancer Research Alliance
Prevent Cancer Foundation
Susan G. Komen
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