Market Program Integrity

January 8, 2019

Submitted electronically via www.regulations.gov Honorable Alex AzarSecretaryDepartment of Health and Human Services 200 Independence Avenue, SWWashington, DC 20201 Re: Patient Protection and Affordable Care Act; Exchange Program Integrity (CMS-9922-P)Dear Secretary Azar: The 17undersigned organizations represent millions of patients and consumers facing serious, acute and chronichealth conditions across the country, including individualswho rely onthe ACA health insurancemarketplaces to obtain their healthcare coverage. Together and separately, our non-profit, non-partisan organizations are dedicated to working with the Administration, members of Congress and state governments on a bipartisan basis to protect the health and wellbeing of the patients and consumers we represent.Our organizations are deeply concerned about the potential for the “Patient Protection and Affordable Care Act; Exchange Program Integrity” rule to cause consumerconfusion, potentially resulting in the termination of insurance coverage. We therefore urge the Department of Health and Human Services (HHS) to rescind sections of the proposed rule that requires patients and consumers pay a separate premium for services identified in Section 1303 of the Affordable Care Act (ACA). In March of 2017 our organizations agreed upon three principles1to guide any work to reform and improve the nation’s healthcare system. These principles state that: (1) healthcare must be adequate, meaning healthcare coverage should cover treatments patients need including all the services in the essential health benefit package; (2) healthcare should be affordable, enabling patients to access the treatments they need to live healthy and productive lives; and (3) healthcare should be accessible, meaning that coverage should be easy to understand and not pose a barrier to care. Enrollment should be easy to understand, and benefits should be clearly defined.As drafted, the proposed ruledoes not meet the standards set forth in our agreed upon principles.The rule wouldrequire insurers to billmarketplace enrollees, either electronically or via mail, twoseparate premiums: one for the base premium and anotherfor the premium for servicesidentified in Section 1303 of the ACA. The marketplace enrollee is then required to make two sperate payments, or face losing their coverage entirely.We believe this will create confusion for patients and consumers and could lead to losses in coverage, including for those with serious, life-threatening illnesses.The Department should do all it can to make coverage as easy to navigate as possible and facilitate enrollment for all who need insurance. This proposal, if finalized, would not ease the burden on consumers and, could instead, undermine the Department’s responsibility to enroll patients in marketplace coverage. The patients we represent needreliable healthcare coverage to manage their disease and lead healthy, productive lives.The connection between health insurance and health outcomes is clear and well documented. Uninsured patients with chronic conditions, including diabetes, cardiovascular disease and mental illness, had worse health outcomes than their insured counter-parts.2Similarly,the Urban Institute found that the uninsured were less likely toreceive routine care orbe screenedfor seriousillnesses such ascancer.3For people with cystic fibrosis, even small gaps in coverage can disrupt access to critical care, increasing the risk of lung infection and hospitalization. For pregnant women, lack of access to timely, quality health care can have lifelong consequences for them and their infants. It is unacceptable to create administrative confusion that could lead to the loss of coverage for our patients. Given the potential to seriously harm the populations we serve, we urge the Department not to finalize the rule as currently drafted.It will create confusion around premiums and jeopardizepatients’ability to maintain meaningfulhealthcarecoverage. For the patients our organizations represent, this could mean serious and potentially fatal health consequences. Thank you for the opportunity to submit comments on this rule. Sincerely, Adult Congenital Heart Association American Diabetes Association American Liver Foundation American Lung Association Cystic Fibrosis Foundation Global Healthy Living Foundation Hemophilia Federation of America Leukemia & Lymphoma Society March of Dimes Mended Little HeartsNational Alliance on Mental Illness National Health Council National Hemophilia FoundationNational Multiple Sclerosis Society National Organization for Rare DisordersUnited Way Worldwide WomenHeart: The National Coalition for Women with Heart DiseaseCC:The Honorable Seema Verma, Administrator,The Centers for Medicare and Medicaid Services1Consensus Healthcare Reform Principles. Available at: https://www.lung.org/assets/documents/advocacy-archive/consensus-healthcare-reform.pdf2Institute of Medicine (US) Committee on the Consequences of Uninsurance. Care Without Coverage: Too Little, Too Late. Washington (DC): National Academies Press (US); 2002. 3, Effects of Health Insurance on Health. Available from: https://www.ncbi.nlm.nih.gov/books/NBK220636/3Urban Institute. Cover Missouri Project: Report 1: Consequences of the Lack of Health Insurance on Health and Earnings. Available at: https://www.urban.org/sites/default/files/publication/50321/1001001-Consequences-of-the-Lack-of-Health-Insurance-on-Health-and-Earnings.PDF