Streamlining consumer experiences, enrollment proposed for 2017 marketplace

The Centers for Medicare and Medicaid Services (CMS) has proposed changes that would improve plan choice and competition for consumers participating in the health insurance marketplace, as well as improve the consumer experience during both the selection process and use of the health insurance plans starting in 2017. The Patient Protection and Affordable Care Act (ACA) reforms include the premium stabilization programs, i.e. risk adjustment, reinsurance, and risk corridor, and rules that are intended to mitigate the potential impact of adverse selection and stabilize the price of health insurance in the individual and small group markets. The changes would address states’ ability to operate exchanges by creating a new exchange model using federal eligibility and enrollment infrastructure. The proposed rule, issued as an advance release and set to officially publish on December 2, 2015, as the annual Notice of Benefit and Payment Parameters for 2017, governs participation in the health insurance marketplaces. CMS will accept comments on the proposed rule through December 21, 2015.

Small business options. Employees with health insurance plans in the federal Small Business Health Options Program (SHOP) would have more options for plan years starting in 2017. Under the proposed rule, employers would be able to offer all plans across all levels of coverage from one insurance company. The intent is that employers would have more choices as they determine what coverage to offer their employees. Under current regulations, employers participating in the federal SHOP marketplace can offer their employees either one health plan and/or one dental plan, or all health and dental plans across one metal level (or, for dental plans, across all actuarial values).

Federal infrastructure. CMS would establish a new exchange model, the State-based Exchange on the Federal platform (SBE-FP), which would allow state-based exchanges to use federal eligibility and enrollment infrastructure to perform certain processes. Under the proposed rule, the SBE-FP would be required to enter into a federal platform agreement with HHS that would define a set of mutual obligations, including the set of federal services upon which the SBE-FP relies. Certain requirements that were previously only applicable to qualified health plans (QHPs) offered on a federally facilitated exchange (FFE) and their downstream and delegated entities would apply to QHPs offered on an SBE-FP and their downstream and delegated entities. In addition, agents and brokers facilitating enrollments through SBE-FPs would need to comply with the FFE registration and training requirements. For 2017, CMS would institute a user fee for QHPs offered through SBE-FPs to offset the federal costs of providing this infrastructure.

Standardized plan options. Under the proposed rule, states would establish a provider network adequacy standard for health plans in the federal marketplace, subject to minimum criteria to be established at a subsequent date. CMS also is evaluating additional efforts to support transparency and consumer decision-making as it relates to network adequacy. As such, the agency is proposing whether designation of network strength, e.g. indicating whether a plan has a broad number of doctors or health facilities in network to choose, could improve the consumer experience in subsequent years.

Plan comparisons. CMS also has proposed to give issuers the choice of offering plans with standardized options, such as cost-sharing, to facilitate consumers’ ease in comparing plans. Health plans would not be required to issue such plans and could continue with variable plan designs.

Additional consumer expenses. CMS would require that health plans in the federal marketplace count certain out-of-pocket expenses on unexpected out-of-network services towards a policyholder’s annual out-of-pocket maximum, if the service was performed at an in-network facility and advance notice was not provided. For instance, if a patient who had surgery at an in-network facility finds out later that their anesthesiologist was not part of the health plan’s network, cost-sharing charges for that anesthesiologist’s services would count toward the out-of-pocket maximum, protecting the patient against additional financial liability. Currently, out-of-network cost-sharing charges are generally not counted towards the out-of-pocket maximum.

Navigator assistance. Marketplace navigators would see their duties expand under the proposed rule, include specific post-enrollment assistance activities such as appealing adverse marketplace eligibility determinations, applying for exemptions through the marketplace, and navigating the transition from coverage to care.

Other changes. Beyond the plan choice and competition and consumer experience changes, CMS’ proposed rule would seek to improve the marketplace by:

• streamlining direct enrollment so that customers can more easily use websites of agents and brokers, decreasing administrative costs for issuers;

• keeping the federal marketplace user fee stable for 2017;

• discussing options on transitioning consumers more smoothly from marketplace coverage to Medicare; and

• recalibrating the risk adjustment formula using most recent data to provide greater accuracy of payments.

SOURCE: 80 FR 75488, December 2, 2015.

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