Health Reform WK-EDGE Consumer-friendly changes coming to marketplace plans
Monday, March 14, 2016

Consumer-friendly changes coming to marketplace plans

By Michelle L. Oxman, J.D., LL.M.

Changes are coming to the health insurance marketplaces for the 2017 enrollment period. In addition to the annual update to cost sharing limitations and the parameters for risk adjustment, risk corridors, and reinsurance, the CMS Final rule announced plans to make the information displayed on the marketplace more useful to consumers and easier to understand and expanded the types of assistance that navigators must offer to consumers (Final rule, 81 FR 12204, March 8, 2016).

Comparing plans. Several new features should help consumers compare qualified health plans (QHPs) more effectively. First, CMS is standardizing the cost sharing structure so that issuers are encouraged to offer certain specified options with respect to cost sharing at the bronze, silver, and gold levels. The display available on the exchange will use the standardized options to show the differences between plans more clearly.

CMS also plans to rate QHPs according to three levels of network adequacy, a basic level for the narrowest networks, a standard level, and a broad level. The agency noted that it has “a goal of starting in 2017.” It did not finalize the proposal to adopt specified time and distance standards, for network adequacy, however.

Premium adjustment percentage. Under the Final rule, the premium adjustment percentage (PAP) is 13.3 percent, which is equivalent to an average annual increase of 4.3 percent since 2013. The PAP is used to calculate the limits on cost sharing, the affordability percentage for calculation of an assessable payment under I.R.C. §1980H, and the required contribution percentage for an individual with access to employer-sponsored insurance to qualify for a hardship exemption under IRC § 5000A.

Cost sharing. In 2017, the deductible for a silver plan will be $3,500. The copayment for generic drugs will be $15, and the annual limit on cost sharing will be $7,150 for single coverage and $14,300 for family coverage. Beginning in 2018, issuers will be required to count a plan member’s payments to out-of-network providers who furnished services at a network facility toward the member’s cost sharing limit.

Patient safety requirement. Issuers of QHPs that contract with a hospital with at least 50 beds must verify that the hospital has a patient safety program. Hospitals may meet this requirement through membership in a patient safety organization or by demonstrating that they have an evidence-based system of data collection and review of patient safety events to reduce harm from all causes.

Open enrollment dates. For the 2017 and 2018 plan years, open enrollment will begin on November 1 of the year preceding the plan year and end on January 31 of the plan year. Enrollment for 2019, however, will begin on November 1, 2018, and end on December 15, 2018.

New duties for navigators. The health insurance exchanges may require navigators to help consumers with understanding the process of appeals of determinations of eligibility for the exchange, exemptions from the requirement to maintain minimum essential coverage or to make shared responsibility payments, and how to claim the exemptions on their tax returns. Navigators may also be required to help consumers understand the health insurance exchange-related components of the process for reconciling advance premium tax credits and the resources that are available at the Internal Revenue Service.

SHOPs. Small business health options programs (SHOPs) that use the federally facilitated marketplace will be permitted to offer a “vertical choice” of plans at all metal levels from the same issuer. The states may recommend against the availability of this option for their SHOPs if they believe it would not be beneficial in their markets.

Notice of changes to network. When a provider leaves its network, a QHP issuer must make a good faith effort to provide plan members for whom the provider is a primary care provider (PCP) or who see the provider regularly at least 30 days’ notice of the departure. If the provider’s contract is terminated without cause, the QHP must allow the member to continue treatment until the course of treatment is complete or for 90 days, whichever is shorter.

Risk adjustment and reinsurance. The temporary risk corridors and reinsurance payments will end after the 2016 plan year as provided in Section 1342 of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148). Risk adjustment payments based on risk corridors will continue under ACA Section 1343, however, and will also be relevant to the question of whether a plan must pay rebates to consumers.

FederalRegisterIssuances: FinalRules NewsFeed BenchmarkBenefitNews CostSharingNews HealthInsuranceExchangeNews IndividualMandateNews ReinsuranceNews SHOPNews

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