"YOU get an exemption! YOU get an exemption! EVERYONE gets an exemption!"

Last month I noted that while Congressional Republicans spent all of 2017 desperately attempting to "blow up" the Affordable Care Act via a combination of legislation, the Trump Administration simultaneously tried to tear down the law via various regulatory sabotage efforts. This year the GOP Congress appears to have mostly given up on their mischief (they did manage to partially wound the ACA by repealing the individual mandate), the Trump Administration is doubling down on regulatory sabotage, laying what I've termed "Regulatory Siege" to the law.

In my mind, "phase one" included the non-legislative stuff Trump did last year, including stuff like cutting off CSR reimbursements, slashing the Open Enrollment Period in half, slashing marketing funding by 90%, slashing the outreach budget by 40% and so on. "Phase two" includes the previously-announced #ShortAssPlans executive order, CMS allowing work requirements for Medicaid and so forth (individual mandate repeal belongs here as well, although that was legislative, not regulatory...although there's overlap as you'll see below).

Yesterday brought Phase Three.

The Notice of Benefit and Payment Parameters is a formal annually-produced docuemnt which is sent out by the HHS Dept. to insurance carriers and other involved healthcare players letting them know what the regulatory rules are gonna be for the upcoming Open Enrollment Period.

I don't know how much of these types of regulatory changes are inherently within the scope of the HHS Secretary and/or the CMS Administrator, but the bottom line is that for better or for worse, the ACA gives the HHS Sectretary quite a bit of elbow room to make changes to the rules of the road every year...and given who's running the show these days, the 2019 NBPP ain't a pretty picture:

HHS Notice of Benefit and Payment Parameters for 2019 Fact Sheet

The HHS Notice of Benefit and Payment Parameters for 2019 final rule released on April 9th, 2018 includes CMS standards for issuers and Exchanges, generally for plan years beginning on or after January 1, 2019.

The Patient Protection and Affordable Care Act has led to higher premiums and fewer choices. Between 2013 and 2017, the average premiums more than doubled in the states using the Federal Health Insurance Exchange platform and half of Americans live in areas with only one issuer to choose from. Additionally, the number of issuers was at its highest in 2015 with 252 issuers participating in the Exchange, this year that number has been reduced to only 132 issuers.

These are factually accurate statements...which completely ignore the fact that two of the main reasons "average premiums have more than doubled" are a) pre-ACA individual market policies kept premiums low by cherry-picking only healthy enrollees while often being little more than "coupon books" in terms of services offered, and b) due specifically to deliberate sabotage efforts on the part of the Congressional GOP and Trump Administration. There are other reasons as well, of course, not all of which can be pinned on the GOP (the original "You Can Keep It" transitional plan decision, for instance), but the opener of the NBPP is disingenuous at best.

The final rule is intended to advance the Administration’s goals for increasing flexibility, improving affordability, strengthening program integrity, empowering consumers, promoting stability, and reducing unnecessary regulatory burdens associated with the Patient Protection and Affordable Care Act in the individual and small group health insurance markets.

"Unnecessary regulatory burdens" is obviously a wee bit subjective, to put it mildly.

The Final Annual Issuer Letter was also released today. This Letter provides operational and technical guidance to issuers that want to offer Qualified Health Plans (QHPs) in the Federally-facilitated Exchanges (FFEs) for plan years beginning in 2019.

Important: For the most part, the NBPP only applies to the 34 states completely run through the Federal exchange at HealthCare.Gov (there are 5 more states which piggyback on HC.gov but which are legally still defined as running their own exchanges; I don't think the NBPP applies to them but could be wrong).

CMS also issued new guidance today expanding hardship exemptions. Under this hardship exemption guidance, individuals who live in counties with no issuers or only one issuer, will now qualify for a hardship exemption from paying the Affordable Care Act’s penalty for not having coverage. The guidance also allows CMS to consider a broad range of circumstances that result in consumers needing hardship exemptions.

Annnnd there you have it. The Congressional GOP officially repealed the ACA's individual mandate back in December...but it doesn't go into effect until next year, meaning that it's supposed to still apply to people who didn't get ACA-compliant healthcare coverage for 2017 or 2018. As I've been warning about for months, this has caused a ton of confusion as several million people are under the impression that the mandate has already been repealed and that they're therefore off the hook for last year and this year, which isn't the case.

However, as various healthcare wonks including myself warned way back on January 20, 2017 (i.e., the very day Trump took office):

yes individual mandate exemptions will be passed out like pacifiers at a rave.

— David Anderson (@bjdickmayhew) January 21, 2017

Yup, sure enough, while the mandate penalty may technically still be the law of the land, Alex Azar & Seema Verma are indeed planning on doling out "hardship exemptions" left and right like Oprah Winfrey handing out cars to her audience.

In addition, CMS issued a bulletin today to extend the transitional policy for one additional year. This policy allows for the transition to fully Affordable Care Act compliant coverage in the individual and small group health insurance markets until 2019. CMS is releasing this bulletin to provide states additional flexibility and control over their health insurance markets.

(sigh) This is a Bad Thing®, but as I noted above, this one really can't be pinned on Trump or the GOP; the transitional (or "grandmothered") plan policy was put into place by the Obama Administration in response to the #YouCanKeepIt brouhaha back in November 2013, and somehow it ended up being bumped out again year after year to the point that there's effectively no real distinction between the "temporary" transitional plans and the permanent "grandfathered" plans anymore. So, while I'm not happy about this, there's not much I can say about it.

Essential Health Benefits (EHB)

CMS is providing states with additional flexibility in how they select their EHB-benchmark plan for plan years 2020 and beyond, to provide states with additional choices with respect to benefits and affordable coverage. CMS is offering states substantially more options in what they can select as an EHB-benchmark plan. Instead of being limited to 10 options, states are allowed to:

  • 1) choose from one of the 50 EHB-benchmark plans that other states used for the 2017 plan year;
  • 2) replace one or more of the ten required EHB categories of benefits under its EHB-benchmark plan used for the 2017 plan year with the same categories of benefits from another state’s EHB-benchmark plan used for the 2017 plan year (for example, a state may select the prescription drug coverage EHB category from another state’s EHB-benchmark plan used for the 2017 plan year and the hospitalization EHB category from a third state’s EHB-benchmark plan used for the 2017 plan year); or
  • 3) otherwise select a set of benefits to become its EHB-benchmark plan, provided the EHB-benchmark meets the scope of benefits requirements and other specified requirements.

The bad news is that this means that carriers in any state can pick the lowest-common denominator in a race to the bottom for EHBs. The good news is that according to Margot Sanger-Katz of the New York Times, that doesn't really mean much in practice as there's not a whole lot of variance between the states anyway.

Standardized Options

CMS is not specifying standardized options for the 2019 plan year. In the 2017 Payment Notice, CMS introduced standardized options to specify QHP designs that different insurers could provide using the same standardized cost-sharing structure, including the same deductible, co-pay and coinsurance rates. For 2017 and 2018 plan years, HHS encouraged issuers to offer standardized plans and highlighted these plans on HealthCare.gov by providing them a differential display. CMS will not be encouraging standardized options or providing differential display of standardized options on HealthCare.gov for 2019. Agents and brokers and issuers that assist consumers with QHP selection and enrollment will also not be required to provide differential display of standardized options. CMS heard concerns that providing differential display for these plans may limit enrollment in coverage with plan designs that do not match the standardized options, removing incentives for issuers to offer coverage with innovative plan designs.

Arrrrrrgh! This is a big step in the wrong direction (shocker, I know). Several state-based exchanges such as California and Massachusetts have fairly strict standardization requirements for policies offered on their exchanges, which reduces confusion and clutter (as well as what Dave Anderson terms "silver gapping" to game the system) while still allowing for a healthy amount of variety in the plan offerings. HealthCare.Gov started offering standardized plans a couple of years ago but never made them mandatory (which kind of defeats the point of having them in the first place). Instead of making them mandatory, CMS is now apparently scrapping them altogether.

Qualified Health Plan (QHP) Certification Standards

CMS is returning important oversight authority back to the states by expanding their role in the QHP certification process for Federally-Facilitated Exchanges (FFEs). CMS will continue to defer to the States’ reviews of network adequacy provided the State has a sufficient network adequacy review process for plan years 2019 and beyond. CMS had previously introduced this approach in the Market Stabilization rule, however, it only impacted plan year 2018.

In addition, CMS is eliminating requirements for State-Based Exchanges using the Federal Platform (SBE-FPs) to enforce FFE standards for network adequacy and essential community providers. Instead, CMS is allowing SBE-FPs the flexibility to establish their own standards, which CMS believes will further empower SBE-FPs to use their QHP certification authority to encourage issuers to stay in the Exchange, enter the Exchange for the first time, or expand into additional service areas.

This refers to the 5 states I mentioned above (Arkansas, Kentucky, Nevada, New Mexico and Oregon) which officially operate their own ACA exchanges but are piggybacked on the HealthCare.Gov platform. To be honest, I'm not sure whether this is a good or bad thing, since these states are primarily just using the federal exchange's technology platform anyway.

CMS is also eliminating the meaningful difference requirement for QHPs. The meaningful difference standard was implemented to make it easier for consumers to understand differences between plans, and choose the right plan option for them. However, with fewer issuers participating in the Exchanges, and fewer plans for consumers to choose from, CMS is removing these standards, as they are no longer necessary. Consumers are not facing the problem of too many plans to choose from. Eliminating this requirement should help encourage plan design innovation by providing more flexibility to issuers in designing plans, and, as a result, increase plan offerings and choice for consumers.

Ummmm...I'm not sure I get this one at all. If there's only one carrier on the exchange, it still doesn't make any sense to let them clutter up the market with 25 virtually-identical versions of Silver plans. As I noted a couple of years ago:

When [Steve] Jobs took the reins as interim CEO in July of 1997, Apple was making more than 350 different products, many of which seemed redundant, expensive, and outdated. In order to get the company focused on making better products that made more sense to consumers, he cut that number down to just 10. He knew that in order for the company that he co-founded to survive, it needed to be leaner and more focused, than it had been under previous CEO Gil Amelio.

At the core of the new line-up were four products, a consumer laptop and desktop, as well as a laptop and desktop designed for professionals. Each of those computers had various configurations of course, but as far as Apple was concerned, the product line remained extremely streamlined and simple. This allowed the company to focus on new technology and design, which resulted in the first iMac, a computer that made waves due to its unique looks, and shift away from traditional IO ports in favor of USB – something that was radical at the time.

Anyway, reversing this policy seems a bit pointless to me, if not devastating.

Navigator Program

CMS is providing Exchanges with more flexibility in the operation of Navigator programs, by removing the requirements that each Exchange must have at least two Navigator entities, and that one of these entities must be a community and consumer-focused nonprofit group. Also, CMS is removing the requirement that each Navigator entity maintain a physical presence in the Exchange service area. Removing these requirements gives Exchanges more flexibility to ensure that grant funding goes to the strongest applicants.

Ugh. I don't get the physical presence part (some state exchanges have their own renrollment kiosks or even retail-style storefronts, but I didn't think HC.gov did), but given the 40% budget cut to Navigator programs last year, this is another serious blow to the program. In addition, CMS is now specifically stating that the "strongest applicants" no longer have to be "community/consumer-focused nonprofit groups"...which sure as hell sounds like "dump all the money on private, profit-based grifters!" to me. I'm sure that's paranoia given the sterling record of integrity of the Trump Administration...

Risk Adjustment

CMS is amending the HHS-operated risk adjustment program in three ways. First, to provide continued stability and predictability for issuers, the risk adjustment model for the 2019 benefit year will be recalibrated using blended coefficients from the 2016 enrollee-level External Data Gathering Environment (EDGE) data and 2014 and 2015 MarketScan® data. Enrollee-level EDGE data includes the actual experience of individual and small group market enrollees, and therefore using the 2016 enrollee-level EDGE data will more closely reflect the relative risk differences in these markets. Second, we are removing two severity-only drug classes from the 2019 benefit year risk adjustment models that no longer meaningfully predict incremental risk. Third, in states where HHS operates the risk adjustment program, CMS will provide States with the flexibility to request a reduction to the otherwise applicable risk adjustment transfers in the individual, small group or merged market by up to 50 percent beginning with the 2020 benefit year. States requesting such a reduction must provide supporting evidence and analysis that show the state-specific rules or market dynamics warrant an adjustment to more precisely account for the relative risk differences in the state’s market, and justify the reduction amount requested.

I'm gonna be blunt here: I don't understand how risk adjustment works at all, so I'm gonna skip over this one since I haven't a clue whetehr it's a good or bad thing.


Exchanges will be able to make a determination of lack of affordable coverage based on projected income using the lowest cost Exchange metal level plan offered through the Exchange when there is no bronze level plan available in the service area.

OK, that's reasonable I suppose, although to be honest I'm not quite sure I understand how the states have been doing this until today. Could be just clarifying an unofficial method?

Stand Alone Dental Plan Actuarial Value

CMS is removing the actuarial value (AV) levels of coverage standard for stand-alone dental plans (SADPs) in the Exchanges that required SADPs to cover pediatric dental EHB at one of two AV levels, either a low (70 percent +/- 2 percentage points) or high (85 percent +/- 2 percentage points) AV level. The Patient Protection and Affordable Care Act (PPACA) does not specifically require SADP issuers to offer coverage at the high or low levels of AV. By removing the AV level requirement, SADP issuers will have the opportunity to offer more flexible plan designs to consumers. Consumers will benefit by having a greater range of SADPs from which to choose.

Translation: "Since the ACA itself doesn't specifically require stand-alone dental plans to not be junk insurance, we're going to start allowing stand-alone dental junk insurance!

Verification for Eligibility for Insurance Affordability Programs

To promote program integrity, CMS will generate annual income inconsistencies for certain consumers who attest to income that is higher than the amount found in income data received from the Exchange’s trusted data sources (Internal Revenue Service and the Social Security Administration, or other current income data sources) by more than a reasonable threshold amount. This new check will only be for households for which trusted data sources reflect income below 100% FPL, because an accurate eligibility determination is critical for consumers near this threshold to ensure that advance payment of the premium tax credit (APTC) is not paid on behalf of consumers who are statutorily ineligible. CMS also modifies the requirements for Exchanges to verify eligibility for and enrollment in qualifying employer-sponsored coverage, such that Exchanges will continue to have the option to conduct an alternative process to sampling for benefit years through 2019.

Translation: The ~2.6 million or so people caught in the Medicaid Gap across 19 (soon to be 18) GOP-controlled states which have refused to expand Medicaid have been truly and severely screwed, because they don't qualify for Medicaid but also earn too little to qualify for ACA tax credits for exchange-based policies. As a workaround, some people who earn slightly less than 100% of the Federal Poverty Line (around $12,000/year for a single adult with no kids) have supposedly been doing a bit of number-shuffling to squeak their official income just over that 100% mark. Apparently Seema Verma has decided that these people aren't being screwed over enough so is cracking down on this practice.

To further promote program integrity, CMS is removing the requirement prohibiting Exchanges from discontinuing APTC because the tax filer has failed to file a tax return and reconcile APTC paid for past benefit years, if the Exchange does not first send notice directly to the tax filer. Adequate notice and the opportunity for the tax filer to correct the issue is still required, but we believe this is an important program integrity measure to help ensure that APTC is not paid on behalf of enrollees and tax filers who are not eligible due to failure to file and reconcile.

I actually don't have a problem with this one. If you're receiving federal tax credits based on your annual income, it's understandable that the federal government would want you to, you know, file a federal tax return.

HHS-Risk Adjustment Data Validation (HHS-RADV) Requirements

CMS is finalizing several changes to HHS-RADV requirements to ensure the integrity of results while at the same time reducing unnecessary regulatory burdens on insurers. In states where CMS operates the risk adjustment program, CMS performs RADV audits to validate the accuracy of the diagnosis codes submitted by issuers to their respective EDGE servers for the risk adjustment transfer calculation. CMS changes to HHS-RADV include:

  • implementing a simplified approach to making payment adjustments as a result of HHS-RADV error rates that will only adjust an issuer’s risk score when the error rate for a group of hierarchical condition categories (HCCs) is an outlier relative to the error rates for that group of HCCs for all issuers in HHS-RADV for the benefit year being validated;
  • requiring post-transfer adjustments to payment transfers based on the results of the HHS-RADV for insurers that have exited the market;
  • exempting issuers with 500 billable member months or fewer statewide from the requirement to hire an initial validation auditor submit initial validation audit results, or be subject to risk adjustment data validation payment adjustments;
  • changing the data sampling methodology so that the initial sample would only include enrollees from state risk pools with more than one issuer;
  • modifying the minimum data elements required for validation of mental or behavioral health diagnoses to address state law privacy concerns;
  • adding the 2016 benefit year as an initial year of HHS-RADV for which the initial validation auditor may meet an inter-rater reliability standard of 85 percent versus the higher 95 percent standard;
  • clarifying and amending the bases upon which civil money penalties may be imposed for violation of HHS-RADV requirements;
  • providing that demographic or enrollment errors discovered during HHS-RADV would be the basis for an adjustment to the applicable benefit year transfer amount, rather than the subsequent benefit year risk score; and
  • postponing the applicability of the HHS_RADV materiality threshold to begin with the 2018 benefit year, instead of the 2017 benefit year.

Again, risk adjustment is an area I don't understand at all, so I'll take a pass.

Special Enrollment Periods (SEPs)

CMS is aligning the enrollment options for all dependents who are newly enrolling in Exchange coverage through an SEP and are being added to an application with current enrollees, regardless of the SEP under which the dependent qualifies. CMS also amended and standardized the alternate coverage start date options available to consumers newly gaining or becoming a dependent and enrolling due to a birth, adoption, foster care placement, or court order. CMS will allow pregnant women who are receiving health care services through Children’s Health Insurance Program (CHIP) coverage for their unborn child to qualify for a loss of coverage SEP upon losing access to this coverage. Finally, CMS exempts consumers from the prior coverage requirement that applies to certain special enrollment periods if they lived in a service area without qualified health plans available through an Exchange during a recent enrollment period for which they were eligible.

Most of this sounds reasonable, to be honest, but that "for their unborn child" verbage stands out like a sore thumb (or a pregnant woman's belly, I suppose). They really can't help but work in anti-choice language everywhere, can they?

Termination Effective Dates

The rule will make it simpler for consumers to terminate coverage through the Exchanges, by, at the option of the Exchange, allowing enrollees to request same-day or prospective coverage termination dates. Previously most enrollees had to give a 14 day advance notice, prior to termination. The rule also aligns termination effective dates for new Medicaid/CHIP enrollees to this same timeline.

Again, this doesn't seem like a bad thing unless I'm missing something.

Medical Loss Ratio (MLR)

The final rule amends MLR requirements to reduce regulatory burdens in order to stabilize insurance markets, increase insurer participation and expand consumer choice. To start, CMS reduces the burden associated with the Quality Improvement Activity (QIA) reporting requirements by allowing issuers the option to either continue tracking and reporting actual QIA expenses or report a standardized amount equal to 0.8 percent of the issuer’s earned premium for the year for a minimum of 3 consecutive MLR reporting years without having to separately track such expenses.

The rule also modifies the information a state must provide to justify a request to adjust the 80 percent MLR standard in the individual market. The final rule amends various provisions to provide more flexibility to states by permitting requests for adjustments to the individual market MLR standard in any state that demonstrates that a lower MLR standard could help stabilize its individual market, and to streamline the process for applying for such adjustments to reduce burdens for states and CMS.

I'm not sure I follow this entirely, but it sounds an awful lot to me like Seema Verma is giving the carriers a lot of wiggle room to get past the MLR rule requiring that they spend at least 80% of the premiums they receive on actual healthcare claims instead of on gross profits. Yesterday's news about BCBS of Minnesota is probably a perfect example: They have to pay back $30 million to enrollees this year. I presume the rule change above would let them shave off a million or two, although again, I'm not certain about this.

FFE and SBE-FP User Fees

CMS is maintaining the user fee rate at 3.5 percent of premium for FFEs, and setting the user fee for SBE-FPs at 3.0 percent of premium for the 2019 benefit year. The SBE-FP user fee rate represents an increase for SBE-FP states from 2.0 percent established for the 2018 benefit year.

This is confirmation of the very question I've been asking for two months now: Since, as the NBPP itself notes from the beginning, unsubsidized premiums have gone up so much over the past 5 years, why on earth is the user fee--which, remember, is a percentage of policy premiums--going up or staying the same instead of dropping? As I noted in February, HC.gov should have something like twice as much money rolling in from these fees as they did in 2013...even though the bulk of the expenses should have long since been amortized.

I'm sure normal inflation, infrastructure improvements and so on can add some cost to the total, but I find it difficult to believe that it costs twice as much to operate HealthCare.Gov as it did a couple years back, seeing how the technical problems have long since been resolved and especially seeing how the Trump Administration slashed marketing and outreach budgets by over a hundred million dollars last year.

In any event, that 50% fee increase for the SBE-FP states (Arkansas, Kentucky, Nevada, New Mexico and Oregon) is the main reason why Nevada has decided to drop back OFF the federal exchange next year.

Small Business Health Options Program (SHOP)

By removing regulatory burdens, CMS is streamlining the Small Business Health Options Program (SHOP) enrollment process in the SHOP Exchanges using the Federal platform for employers to use an issuer-based enrollment approach. This change allows SHOPs to eliminate the online enrollment process and allows employers to enroll directly with an Exchange-registered agent, broker, or issuer. SHOP Exchanges are no longer required to provide employee eligibility, premium aggregation, and online enrollment functionality and for plan years beginning on or after January 1, 2018 FF-SHOPs and SBE-FP for SHOP will no longer be providing these services. Due to the fact that SHOP Exchanges have experienced much lower enrollment than expected and have proved challenging for many states to establish, these functionalities have not been cost effective. These changes become effective on [insert effective date of this rule] for plan years beginning in 2018 and later. State-based SHOP Exchanges have the flexibility to maintain current operations of their online SHOP enrollment platforms, or take advantage of the regulatory flexibilities available through the final rule to design a SHOP that best meets the needs of the small group market in their state. The Small Business Health Care Tax Credit will continue to be available to employers who enroll their small group in a SHOP plan.

This was mostly announced last year, and I honestly couldn't get too worked up about it. SHOP is successful in a handful of states but it's frankly kind of a dud nationally, and group insurance is generally enrolled in through a whole different process anyway.

Minimum Essential Coverage (MEC) Recognition for CHIP Buy-in Programs

CMS did not finalize the proposed categorical designation of CHIP buy-in programs that provide identical coverage to the state’s Title XXI CHIP program as minimum essential coverage (MEC) since they have recently been statutorily designed as MEC. CMS will verify the MEC status of CHIP buy-in programs for states that submit plan documentation for the CHIP buy-in program and the state’s title XXI program to CMS for comparison. This optional verification will provide clarity for states and consumers and alleviate burdens on states.

Not too familiar with this one.

Rate Review

CMS makes several changes related to rate review to reduce regulatory burden for states and issuers by recognizing the primary role of state regulators in the rate review process. These changes include:

  • exempting student health insurance coverage from the Federal rate review process;
  • increasing the default threshold for rate increases subject to review to 15 percent from 10 percent;
  • allowing states with Effective Rate Review Programs to have different submission deadlines for issuers that only offer non-QHPs; and
  • reducing the advanced notification that states must give CMS about the posting of rate increases from 30 days to 5 business days if the State will be posting prior to the date specified by CMS.

Ugh. I don't know much about student policies (and to be honest I don't think I've ever written a single blog post about them other than to acknowledge that they exist), but that 10% to 15% bump is ugly. CMS is basically saying that they're OK with carriers tacking on an extra $30/month to everyone's pre-subsidy premium as long as the state regulators are OK with it, which doesn't sound like "helping to lower costs/burdens for the consumer" to me.

I'm less bothered by the reduction in rate change notifications, since those seem to constantly change on a weekly basis for some carriers right up until the contracts are locked in every year anyway.

UPDATE: A few additional tidbits from the 500+ page Rule itself (remember, everything above is just the summary version), as presented by Sanger-Katz via Twitter:

  • People will also be able to avoid paying the individual mandate penalty if the only affordable plans available in their area cover abortion. This will mean all customers in certain states, including CA and NY, will be able to claim an exemption.

There's some debate amongst wonks as to whether or not CA & NY would be included here, since they run their own exchanges, but the point is that this adds to the "EVERYONE GETS AN EXEMPTION!" meme in the headline.

  • CMS just confirmed new categories of hardship exemption will apply to this year's plans. Likely an unhappy surprise for solo insurers (and insurers in states with abortion coverage requirements), who priced for a mandate this year.

Ouch. Good point. Some carriers did bake a few extra percentage points into their 2018 premium rates just in case the mandate was repealed, but most of them didn't. Those carriers are gonna take a hit this year as some of those who enrolled drop out mid-year upon learning that they won't have to pay the mandate penalty after all.

  • The new hardship guidance has a two-year lookback. Smart people: Does that mean that people who paid the penalty in past years can get retroactive refunds?

I have no idea, but I do know that several GOP members of Congress were trying to make the mandate repeal retroactive during their repeated ACA repeal shenanigans last year.

And finally:

  • Seema Verma said CMS is still considering whether it will restrict silver loading in future years. "That policy is currently under review."

I've written about this a couple of times. I normally wouldn't believe they'd be stupid enough to do this, especially with official 2019 premiums being announced just a week or two before the midterm elections, but...this is the Trump Administration we're talking about...