The Centers for Medicare & Medicaid Services is trying to decide just which plans will and will not qualify for help from one of the three major new health law risk management programs.
CMS talks about the "risk corridor" program eligibility rules in final regulations set to appear in the Federal Register this week.
The Patient Protection and Affordable Care Act is supposed to create the risk corridor program along with a temporary reinsurance program and a permanent risk adjustment program.
The temporary risk corridor program would take cash from exchange plans with claims costs much lower than expected and shift the cash to plans with claims much higher than expected.
The risk corridor program is supposed to be limited to exchange plans. A plan offered both inside and outside the exchange program would be eligible.
The performance of the risk corridor program could determine whether the PPACA exchanges maintain healthy competition and survive, or whether some exchange players crush the competition, develop monopolies in the exchange market, and smother the exchanges.
In the new final regulations -- the same ones that let traditional agents and brokers enroll exchange users through Web brokers' websites -- CMS officials said they would open the risk corridor program to the non-exchange twin of an exchange plan if the non-exchange plan is different only because of state or federal legal requirements.
CMS is revising a provision in the draft version of the regulations to make it clear non-exchange plans that are slightly different from the exchange plans only because of confusion about what the final exchange rules would also be can participate in the program.
CMS is not letting a carrier count a plan sold by one subsidiary inside the exchange and an identical plan sold by another subsidiary outside the exchange as the same plan.