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Home Health Policies: Improvement Proposals for the 2017 Marketplace

Posted by Nathan Hope on Apr 15, 2016

CMS Proposes Improvements for the 2017 Marketplace

Home Health Policies- The Centers for Medicare & Medicaid Services (CMS) today issued the proposed annual Notice of Benefit and Payment Parameters for 2017, governing participation in the Health Insurance Marketplaces. The proposed rule seeks comment on proposals that will provide continued choice and competition for consumers, and a vibrant and growing market for affordable, quality health plans.  The proposed rule seeks to improve the consumer experience, both when individuals shop for health insurance and when they use it.

“As we enter into our third year, the Health Insurance Marketplace continues to grow, with millions of people looking to the Marketplace as their source for quality, affordable health coverage that will be there when they need it. We’re off to a good start with tens of thousands more Americans turning to the Marketplace for health coverage every day, and even more returning for another year,” said Kevin Counihan, CEO of the Health Insurance Marketplaces.  “We look forward to reviewing comments to these proposed rules to make the Marketplaces work even better so that consumers will benefit from choice and competition.” 

To protect consumer access to health care providers and delivery organizations, the proposal asks states to establish a provider network adequacy standard for health plans in the federal Marketplace, subject to minimum criteria that CMS will establish at a later date, with a default time and distance standard otherwise. CMS is evaluating additional efforts to support transparency and informed consumer decision-making as it relates to provider network adequacy, and is requesting comment on whether designating network strength – for instance, indicating whether a plan has a broad number of doctors or health facilities in their network to choose from or not -- could improve the consumer experience in future years.

To make it easier for consumers to compare plans based on key provisions, CMS is proposing to give issuers the choice of offering plans with standardized options such as cost-sharing.  Health plans would not be required to issue such plans and could continue to offer other plans with more variable plan designs, as well as the proposed optional standardized plans, so consumers can choose the plan that’s right for them.14-11-04-CMS

In an effort to reduce surprises consumers may face after buying a policy, CMS is seeking comment on a requirement that health plans in the federal Marketplace count certain out-of-pocket expenses on unexpected out-of-network services towards a policy holder’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, these types of out-of-network cost-sharing charges are generally not counted towards the out-of-pocket maximum.

Recognizing that once consumers enroll in coverage, many still need assistance in understanding and using their coverage, the proposed rule seeks comment on expanding the required duties of Navigators.  The expanded duties would include specific post-enrollment assistance activities such as Marketplace eligibility appeals, applying for exemptions through the Marketplace, and navigating the transition from coverage to care. This proposal is a step forward in engaging and empowering consumers with the resources they need to understand how to use their coverage.

The proposed rule would also increase options for employees in the federal Small Business Health Options Program (SHOP) for plan years beginning in 2017 and beyond. 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 actuarial value, for dental plans). Under the proposal, employers would be able to offer all plans across all levels of coverage from one insurance company. This would give employers more choices as they look for coverage that best suits their employees.

The rule proposes changes and solicits comments on a number of proposals as well as improvements to the premium stabilization programs in an ongoing effort to build the Marketplace in a way that supports a vibrant and competitive environment for issuers and consumers.  Those include:

  • 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, the 4th year of predictability for issuers;
  • Discussing options on transitioning consumers more smoothly from Marketplace coverage to Medicare, so that elderly, often higher-risk consumers, move from the Marketplace risk pool to Medicare;
  • Recalibrating the risk adjustment formula using most recent data to provide greater accuracy of payments;
  • Seeking comment on improvements to the child age rating curve to reflect risk more accurately, so that premiums can be more accurately priced; and
  • Seeking comment on the Open Enrollment period for 2018 and beyond. Under the proposal the Open Enrollment period for 2017 would remain November 1 – January 31.

For a more detailed list of proposals in the rule, visit: https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/index.html  

The proposed rule was placed on display at the Federal Register today, and can be found at:



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