Rich Daly | February 23, 2015
Among changes federal marketplace insurers will face under recently announced rules are a new open enrollment period, tightened directory requirements, and increased out-of-pocket maximums.
Feb. 23—Insurers will not face tighter network-adequacy standards under new requirements for 2016 plans sold in government-run marketplaces.
The Centers for Medicare & Medicaid Services (CMS) released a Feb. 20 letter establishing requirements for 2016 plans sold on the federally operated marketplaces that were created by the Affordable Care Act (ACA). The requirements maintain existing “reasonable access” standards for network adequacy and mandate the submission of detailed network provider data, including information on physicians, facilities, and pharmacies.
CMS plans to follow through on a network-adequacy review that will focus on hospital systems, mental health providers, oncology providers, primary care providers, and dental providers, where applicable. CMS will notify insurers when it sees problems with networks during the review process.
Importantly, CMS said it plans to evaluate expected recommendations from the National Association of Insurance Commissioners (NAIC) on network adequacy as the basis for future requirements for marketplace insurers. The NAIC released a draft-model law in November, updating its Network Adequacy Model Act to serve as a template to assist federal and state lawmakers and regulators in drafting insurance laws and regulations. The previous version, which dates from 1996, needed to be updated to address recent changes in the insurance marketplace, such as the expansive use of narrow networks by ACA marketplace plans.
Also included in the CMS letter to insurers was some tightening of requirements for provider directories, including that the directories be updated at least monthly and be accessible on a plan’s public website without restriction.
Additional Provisions
Other provisions of the CMS letter include plans for the agency to phase in quality and enrollee satisfaction reporting for marketplace plans. CMS is conducting beta testing of reporting in 2015 with a view toward establishing public reporting of quality and enrollee satisfaction data in 2016. The marketplaces will display quality and enrollee satisfaction scores and ratings in 2016 for the 2017 open enrollment period.
A separate rule also released Feb. 20 set out other operational details for next year’s marketplaces, including setting the open enrollment period from Nov. 1, 2015, through Jan. 31, 2016.
The rule addresses protections for insurers that prevent them from experiencing deep financial losses, user fees for the federal marketplaces, cost-sharing subsidy information, and changes to medical loss ratio calculations.
Among the changes are an increase in maximum out-of-pocket costs to $6,850 for individuals and $13,700 for families when obtaining in-network care. The ACA provides no limits on charges for out-of-network care.
Source: HFMA