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Federal Register / Vol. 86, No. 124 / Thursday, July 1, 2021 / Proposed Rules
also be newly eligible for APTC under the new rules. Currently, after passage of the ARP and CMS removal of the 400
percent FPL limit on household income regarding qualifying individuals applying for coverage through an Exchange on the Federal platform, the number of enrollees who did not provide household income has decreased slightly, to just under 472,000, and the number of enrollees reporting a household income greater than 400 percent of the FPL has increased to over 191,000. The number of enrollees eligible for a maximum APTC amount of zero dollars has also increased slightly, to just under 42,000
individuals.162 We expect these trends continue during 2022 in Exchanges on the Federal platform and likely in other State Exchanges, as well, making this clarification especially relevant at that time.
We seek comment on this proposal, including from State Exchanges regarding whether this definition of APTC eligibility reflects their current implementation of the special enrollment period qualifying events per 155.420d6, and if not, whether there are policy concerns about this clarification, or concerns about the burden of making related changes to State Exchanges operations. We also seek comment on whether any group of individuals who may qualify for one or more of the special enrollment periods at 155.420d6 could be harmed by this clarification, and if so, how such harm could be mitigated.

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6. FFE and SBEFP User Fees 156.50
We are proposing an increased FFE
user fee rate of 2.75 percent for the 2022
benefit year, which is higher than the 2.25 percent FFE user fee rate finalized in part one of the 2022 Payment Notice.
We also propose to increase the SBEFP
user fee rate to 2.25 percent for the 2022
benefit year from the 1.75 percent SBE
FP user fee rate finalized in part 1 of the 2022 Payment Notice final rule.163
Based on our estimated costs, enrollment including anticipated transitions of states from the FFE and SBEFP models to either the SBEFP or State Exchange models, premiums for the 2021 and 2022 benefit years, and proposed user fee rates, we expect transfers from the issuers to federal government to be increased by 162 These figures are drawn from internal CMS
analysis as of late May, 2021, almost two months after CMS updated HealthCare.gov to reflect the removal of the 400 percent FPL limit on household income on applicants applying for coverage with APTC.
163 85 FR 6138.

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approximately $200 million in plan year 2022.
We are proposing to repeal the 2023
benefit year user fee rate for the Exchange DE option in FFE and SBEFP
states, which was finalized in part 1 of the 2022 Payment Notice final rule. No state entity has approached HHS to consider this option. Since this option has not been implemented in any state, we do not expect any changes to user fee transfers from issuers to the federal government due to this rescission.
7. Segregation of Funds for Abortion Services 156.280
We propose to amend the separate billing regulation at 156.280e2ii that governs payments for QHPs that provide coverage of abortion services for which federal funds are prohibited.
Under this proposal, we would revert to prior policy that allowed QHP issuers offering coverage of such abortion services flexibility in selecting a method to comply with the separate payment requirement in section 1303. If finalized, acceptable methods for satisfying the separate payment requirement would include sending the policy holder a single monthly invoice or bill that separately itemizes the premium amount for coverage of such abortion services; sending the policy holder a separate monthly bill for these services; or sending the policy holder a notice at or soon after the time of enrollment that the monthly invoice or bill will include a separate charge for such services and specify the charge.
The 2019 Program Integrity Rule extensively detailed the anticipated financial and operational burdens from the separate billing regulation. We believe these proposals will remove the significant burden associated with the separate billing regulation. Those burdens included costly estimates for issuer implementation of the technical build to implement the necessary system changes to support separate billing and receipt of separate payments, which would require significant changes to current billing practice and pose increased challenges for some states and issuers given the mid-plan year implementation timeline. These activities included planning, assessment, budgeting, contracting, building and testing their systems; as well as one-time changes such as billing-related outreach and call center training. The burdens also included ongoing costs related to sending a separate bill, such as those related to identifying impacted enrollees, ensuring billing accuracy, reconciliation, quality assurance, record keeping, document retention, support for enrollees who
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enter grace periods for non-payments, customer service, outreach, and compliance. Issuers would also expected to assume annual materials costs related to printing of and sending the separate bill. We anticipated that State Exchanges would experience increased burden associated with onetime technical changes such as updating online payment portals to accept separate payments and updating enrollment materials and notices that reference binder payments, and ongoing costs related to increased customer service, outreach, and compliance.
We also stated in the 2019 Program Integrity Rule that QHP issuers were likely to consider these new costs when setting actuarially sound rates and that this would likely lead to higher premiums for enrollees. Specifically, we estimated there would be an approximate premium impact of up to 1.0 percent in plan year 2021 and each year thereafter states with QHP issuers offering coverage of abortion services for which federal funds are prohibited. We also estimated that enrollment would be slightly reduced in the impacted states as a result of the increase to premiums.
In plan year 2021 and each year after, we estimated that APTC amounts would increase up to $146 million when premium rates reflect the projected additional administrative and operational expense burdens.
We also projected in the 2019
Program Integrity Rule that the FFE
would incur additional costs due to onetime technical changes and increased call volumes and additional customer services efforts. We estimated that the FFE would incur a one-time cost of $750,000 in 2020 and ongoing annual costs of approximately $400,000 in 2020, $800,000 in 2021, $600,000 in 2022, and $400,000 in 2023 onwards to implement the separate billing policy.
We also anticipated that all impacted State Exchanges would incur one-time costs of $9 million in 2020 for necessary technical changes such as updating online payment portals to accept separate payments and updating enrollment materials. In addition, we estimated that State Exchanges would incur ongoing annual costs associated with increased customer service, outreach, and compliance totaling $2.4
million in 2020, $4.8 million in 2021, $3.6 million in 2022, and $2.4 million 2023 onwards for all impacted State Exchanges.
We also anticipated increased costs to consumers for the time required to read and understand the separate bills and seek help from customer service, and additional time to read and send separate payments in subsequent
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