CMS Issues the HHS Notice of Benefit and Payment Parameters for 2016 Proposed Rule
Stronger payment standards for issuers and Marketplaces proposed
The Centers for Medicare & Medicaid Services (CMS) today issued a notice of proposed rulemaking to improve consumers’ experience in the Health Insurance Marketplace and to ensure their coverage options are affordable and accessible. To establish the new consumer standards for 2016, the proposed rule seeks to implement several Affordable Care Act provisions on payment parameters for issuers and Marketplaces. Today’s proposed rule would build on previously issued standards and provisions, which are making high-quality health insurance available to millions of Americans. The proposed rules for 2016 would further strengthen transparency, accountability, and the availability of information for consumers about their health plans.
“It is one of our many goals to strengthen the integrity of programs that fall under the Affordable Care Act to ensure the delivery of quality care with affordable options,” said CMS Administrator Marilyn Tavenner. “CMS is working to improve the consumer experience and promote accountability, uniformity and transparency in private health insurance.”
Beginning in 2014, premium stabilization programs were established under the Affordable Care Act to ensure price stability for health insurance in the individual and small group markets. Today’s proposed rule clarifies provisions related to the premium stabilization programs and the payment parameters applicable to the 2016 benefit year for these programs, and includes a number of additional consumer protections. Taken together, we believe these policies will ensure that consumers have access to high-quality, affordable health insurance.
The rule takes steps to help consumers keep their premiums low. Under current rules, consumers who do not take action during the open enrollment window are generally re-enrolled in the same or similar plan they were in the previous year, even if that plan experienced significant premium increases. Under the proposed rules, we are considering giving consumers the option of being defaulted into a lower cost plan rather than their current plan.
To enhance the transparency of the rate-setting process, the proposed rule includes additional provisions to facilitate public access to information about rate increases in the individual and small group markets for both Qualified Health Plans (QHPs) and non-QHPs using a uniform timeline. It also proposes provisions to further protect against unreasonable rate increases in the individual and small group markets.
The rulemaking also proposes to improve meaningful access standards by requiring that all Marketplaces, QHP issuers, and web-based health insurance brokers provide telephonic interpreter services in at least 150 languages in addition to the existing requirement of providing language services.
To further aid consumers in finding a health plan that best suits their needs, the rule clarifies standards for QHP issuers to publish an up-to-date, accurate, and complete provider directory, including information on which providers are accepting new patients, in a manner that is easily accessible to the general public, including new enrollees, re-enrollees, the state, and the Marketplace. Under these standards, the general public would be able to view all of the current providers for a plan in a provider directory on the plan’s public website through a clearly identifiable link or tab without creating or accessing an account or entering a policy number. This rule proposes that the provider directory be updated at least monthly, and CMS is considering steps to make provider directories available in standard, machine-readable formats.
Additionally, the rule proposes to improve the ability of an enrollee to request access to medications not included on the plan’s formulary by proposing more detailed procedures for the standard exception process, and to add a requirement for an external review of an exception request if the health plan denies the initial request. It also clarifies that cost-sharing for drugs obtained through the exceptions process must count towards the plan’s annual limitation on cost-sharing.
To enhance the consumer experience for the Small Business Health Options Program (SHOP), the rule proposes to streamline the administration of group coverage provided through SHOP and to align SHOP regulations with existing market practices.
Qualified individuals and employers are now able to purchase private health insurance coverage for 2015 through the Health Insurance Marketplaces. Open enrollment for the individual market coverage in 2015 is currently underway, until February 15, 2015, through HealthCare.gov.
The rule also proposes the annual Open Enrollment Period for 2016 and beyond to begin on October 1 and run through December 15 of the year prior to the benefit year.
The proposed rule was placed on display at the Federal Register today, and can be found at:
For more information on today’s proposed rule, please visit, https://www.federalregister.gov/public-inspection
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