Draft policy and operational requirements for the 2017 plan year are available to help issuers seeking to offer qualified health plans (QHPs) participate in the federally-facilitated Marketplaces (FFMs) or Small Business Health Options Program Exchanges (SHOP Exchanges). The proposals, set out in a draft letter, are intended to provide guidance to issuers as they develop their 2017 plan offerings. While the 2017 letter retains much of the content from information set out in prior years, it places renewed focus on issues including network adequacy, discriminatory benefit design, and formulary review. CMS is accepting comments on its proposed guidance until January 17, 2016 (CMS Draft 2017 Letter to Issuers in the Federally-facilitated Marketplaces, December 23, 2015).
QHP certification. The letter indicates that CMS intends to continue to rely on states’ reviews of policy forms and rate filings for market-wide standards as part of the annual QHP certification process. In 2017, issuers must submit a complete QHP application for all plans they intend to offer on an FFM. Additionally, the letter notes that CMS will review all QHP applications for all current and new issuers applying for QHP certification in an FFM. The initial QHP application submission window is April 11, 2016 through May 11, 2016. The final deadline for submission of QHP data is August 23, 2016. The letter explains that the recertification process for 2017 mirrors the process for initial certification of a plan.
Network adequacy. Among the certification standards emphasized in the draft letter is the adequacy of a QHP’s network. All issuers of QHPs will be required to attest that their plans meet the standards set out in 45 C.F.R. Sec. 156.230(a)(2) for network adequacy. Additionally, if the proposals set out in the 2017 Benefit And Payment Parameters Proposed Rule (80 FR 75488) are finalized, issuers will be obligated to meet specific quantifiable network requirements in the form of either time and distance standards or minimum provider-to-covered person ratios for high utilization specialties (see Streamlining consumer experiences, enrollment proposed for 2017 marketplace, December 2, 2015).
Essential community providers. The draft letter discusses how CMS plans to review the essential community provider (ECP) standard for QHPs in 2017. ECPs are providers that serve predominantly low-income and medically underserved individuals. The 2017 ECP standards require that issuers contract with at least 30 percent of available ECPs in a plan’s service area, offer contracts in good faith to all Indian health providers in their service area, and offer contracts in good faith to at least one ECP in each of six specific categories of ECPs, including: family planning providers, federally qualified health centers, hospitals, Indian health care providers, Ryan White providers, and “other” ECPs.
Quality. Section 1311(c)(1)(E) of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) mandates that to be certified as a QHP for participation through a Marketplace, each QHP must implement a quality improvement strategy (QIS). For 2017, issuers are expected to submit a QIS implementation plan report during the 2017 QHP certification process.
Rate review. Additionally, under 45 C.F.R. Sec. 155.1020(a), issuers must submit a justification for rate increases, which will be considered by CMS during certification determinations. When conducting rate review, CMS will consider data submitted by issuers, recommendations of state regulators, and premium rate growth outside the marketplace as compared to the premium rate growth inside the marketplace.
Discrimination and formularies. The draft letter also includes a discussion of discriminatory benefit design. The letter explains to issuers that individuals under age 65 with end stage renal disease (ESRD) are not required to sign up for or enroll in Medicare and may enroll in a QHP, as can individuals who do not have Medicare Part A or Part B. Specifically, the draft letter indicates that a QHP does not provide essential health benefits if it discriminates based on an individual's age, expected length of life, present or predicted disability, degree of medical dependency, quality of life, or other health conditions. Additionally, issuers must use the 2017 benchmark plans when designing their plans. To ensure QHP compliance, CMS also plans to review drug formularies in a number of ways. For example, CMS will perform an outlier review to ensure that plans do not have an unusual number of drugs subject to prior authorization or step therapy requirements.
Other areas impacted. The draft letter also discusses several other issues impacting consumers, like issuer requirements related to provider, formulary, out-of-pocket cost, and other search tools. The draft letter also outlines CMS’ plans for QHP issuer compliance reviews in 2017.
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