Map of United States According tothe Society of Actuaries, cross-border insurance plans would havelittle effect on lowering health insurance premiums, a keyobjective of efforts to drive their creation.

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The Centers for Medicare and Medicaid push to eliminate barriersto the sale of cross-border health insurance plans isn't goingto find the answer in federal regulations, say insurers and healthcare providers.

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Instead, as reported by Modern Healthcare, it's the insurancebusiness itself that restricts such cross-border sales.

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In March, CMS asked for input on how to take away barriers toinsurer cross-border sales, as well as “whether Farm Bureauinsurance plans or short-term, limited duration plans could helpfacilitate the sale of individual market plans.” At present justfour states have laws allowing such sales—Georgia, Maine, Oklahomaand Wyoming—but the results have been mediocre.

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Related: 5 worst and 5 best states for healthcare

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But perhaps the agency hasn't gotten quite the type of feedbackit was looking for.

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In a comment letter, the National Association of InsuranceCommissioners wrote, “These states have each taken adifferent approach, none of which has, to date, resulted ininsurers offering comprehensive health insurance in a state inwhich it is not licensed. This shows that the impediments tointerstate sales are not in federal law but are inherent in thebusiness of health insurance.”

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Lobbying group America's Health Insurance Plans also pointed outthat Section 1333 of the Affordable Care Act permits suchcross-border sales, with one or more states being allowed to sellplans through a health care compact. In fact, AHIP said in itscomments that “The main challenges states face in operationalizingcross-border individual market insurance sales would be the same inany framework. Additional federal action that is outside the optionto create compacts under section 1333 would only compound thosechallenges.”

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And the Society of Actuaries weighed in to questionwhether one objective of expanding cross-border plan sales wouldeven be achieved: lowering premiums. It wrote in its commentletter, “Regardless of where an insurer is licensed, premiums wouldreflect the costs of health care in an individual's state ofresidence. Premiums would reflect local health costs, regardless ofwhere coverage is purchased. This means that individuals in ahigh-cost area would not necessarily have lower premiums availableto them by purchasing coverage from an insurer licensed in alow-cost state.”

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SOA also pointed out the difficulties that could arise fromregulatory challenges: “Providing regulatory authority for networkadequacy based on state of residence is reasonable because it wouldbe difficult for state regulators to regulate out-of-state providernetworks. However, it could be problematic for the state ofresidence to enforce its rules regarding a carrier that isunlicensed in the state because the ultimate enforcement tool isthe ability to suspend the company's license.” Since the state inwhich the problem exists is not the state in which the problemcompany is licensed, it cannot take effective action to compelcompliance with rules.

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It also highlighted the potential for issue and ratingrequirement problems when expanding the sale of non-ACA-compliantpolicies “offered alongside traditional ACA products in eachstate.” If such expansion occurs, it points out, “adverse selectioncould occur between compact products and the ACA products,especially if subsidies are made available for the non-compliantproducts.”

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