While the Senate contemplates what to do about the American Health Care Act (AHCA) passed by the House earlier this month, the Centers for Medicare and Medicaid Services (CMS) took steps last week that could further undermine the Affordable Care Act (ACA).

On Monday, CMS proposed changes for businesses that participate in the Federally Facilitated Small Business Health Options Program (FF-SHOP). Currently, HealthCare.gov serves businesses that obtain SHOP coverage for their employees in 33 states. Under the proposal, these businesses would still use HealthCare.gov to determine their eligibility but would then have to purchase coverage through an insurance agent or broker, or directly from an insurer. CMS said low participation in the SHOP program was a driving factor behind the proposed change, but as one advocacy group pointed out, the additional step necessary to obtain coverage could further reduce participation. 

Similarly, on Wednesday CMS announced a “streamlined direct enrollment process” for consumers that will allow individuals to bypass HealthCare.gov and purchase ACA-approved coverage through a direct-enrollment insurance agent or broker. 

“It is time to get the federal government out of the way and give patients the best tools to make their own health care decisions,” CMS Administrator Seema Verma said in a statement.

Modern Healthcare pointed out that the Obama administration initiated the concept of direct enrollment in proposed rulemaking, but it was never finalized, in part because of concerns over potential privacy risks with third-party vendors. Another concern with the new change is that since not all vendors will offer the range of products available on HealthCare.gov, consumers might not be aware of all available choices. 

Separately, CMS released a checklist on Tuesday for states to use when applying for Section 1332 waivers. States could use the waivers to establish high-risk insurance pools or request funding for state-operated reinsurance programs. Verma said the waivers would “help lower premiums, stabilize the health insurance exchange and meet the unique needs of each state.” The proposed AHCA relies heavily on high-risk pools to address the cost of care for patients with pre-existing conditions. 

 Additionally, CMS finalized a rule on delaying implementation of the mandatory cardiac care bundled payment models, along with the expansion of the Comprehensive Care for Joint Replacement (CJR) Model and the effective date for the Cardiac Rehabilitation Incentive Payment Model. The agency had issued an interim rule in March delaying the start of the cardiac programs and the CJR expansion from July 1 to Oct. 1. The final rule further delays them to Jan. 1, 2018. 

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