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Wednesday, March 9, 2016

CMS Finalizes Health Insurance Plan Standards, Enrollment for 2017

Lydia Mitts

Associate Director of Affordability Initiatives

There's a lot to like in the new “Notice of Benefit and Payment Parameters” rule from the federal government, both about what insurers must offer in the health plans they sell on the federal marketplace in 2017 and about other issues related to enrollment. However, we had hoped the government would release its originally proposed, firmer standards for provider networks and make other parts of this rule mandatory, not voluntary, for insurers.

Overall, the rule, released by the Centers for Medicare and Medicaid Services (CMS) last week, takes significant steps toward making health insurance and care more affordable and making it easier for consumers to compare health plans. In this blog we discuss a number of specific provisions of the rule that will most affect people who buy health insurance through the marketplace. These include:

  • Promotion of standardized plans for insurers to offer in the federally facilitated marketplace
  • Protections to ensure that consumers have access to providers in their health plan’s network
  • Dates for future open enrollment periods and provisions regarding the role of assisters

CMS encourages, but does not require, standardized health insurance plans

CMS announced that it will encourage health insurers in the federal marketplace to offer standardized plans that cover more basic health care services before consumers meet their deductibles. These new plan options will be available in the 2017 plan year.

This is good news for consumers shopping for insurance through the federal marketplace. For example, the silver standardized plan will only charge copays for primary care, specialty care, mental health visits, certain prescription drugs, and urgent care.

Offering more plan options that cover basic care pre-deductible is essential to ensuring that consumers can obtain the care they need to stay healthy, manage chronic conditions, and treat illness early. For many lower- and middle-income families purchasing insurance through the marketplace, high deductibles can pose a serious barrier to obtaining needed care.

These new standardized plan options ensure that deductibles do not stand in the way of consumers obtaining basic care.

In future years, CMS should strongly consider requiring that insurers offer these plans to ensure that consumers in every state with a federal marketplace have these coverage options.

Currently, seven state-based marketplaces already require insurers to offer standardized plan options. These have proven very successful. While the federal government has decided not to require that insurers in federal marketplace offer these plans, it does plan to prominently promote these plans on HealthCare.gov.

More than 9 million people could benefit from these new plan options if insurers in all states that use the federal marketplace opt to sell them. We hope that insurers across all federal marketplace decide to offer the standardized plans, as these plans ensure that enrollees can immediately afford much-needed care before reaching their deductible.

CMS opts not to establish measurable standards for access to in-network providers

In the final rule, CMS stepped back from the stronger consumer protections it originally proposed. These would have required that all federal marketplace states adopt measurable standards showing whether health insurance provider networks are adequate to meet consumers’ needs.

CMS’s decision not to require these standards in the final rule raises concerns regarding consumers’ ability to obtain services from in-network providers that these consumers are guaranteed under their insurance plans.

The quantitative standards would have required affected states to assess each marketplace plan’s network on (at least) one of the following criteria:

  • Whether there are sufficient numbers of providers by specialty to serve plan enrollees (a “provider to enrollee ratio”)
  • Whether plan enrollees can reach different specialists within a reasonable travel time and distance

States that failed to adopt such standards would have been subject to time and distance standards applied by CMS.

CMS signals expectation that states enact network standards

Despite its decision to forgo quantitative network adequacy standards in the final rule, CMS is still directing states to implement protections to ensure that consumers will have access to appropriate providers, in a timely manner, without traveling too far.

CMS made clear it expects that, “all States, including FFE States [those with federal marketplaces], will actively implement these provisions.”

It also referenced the unanimous approval of the National Association of Insurance Commissioner’s (NAIC) Network Adequacy Model Act and how it highlights “specific quantitative standards.” CMS will monitor states’ progress toward enacting the NAIC act this year.  And in future rulemaking, CMS will revisit the standards outlined in the proposed rule.

More evidence of CMS’s support for the use of quantitative standards appears in the 2017 Letter to Issuers in the Federally Facilitated Marketplaces, also released last week. The letter reveals that CMS itself uses quantitative metrics to assess enrollees’ access to specific providers and facilities for those states where it performs plan oversight functions. The transparency of these standards is a step toward the goal of full accountability for network adequacy.

Rule includes other protections to ensure consumer access to health plan providers

Despite the setback on measurable network standards, CMS also finalized other protections that help to ensure consumer access to in-network providers and to information about those providers. The Letter to Issuers introduces a new system for labeling federal marketplace plan networks based on their breadth.

Starting in 2017, each plan will receive a designation as having a “basic,” “standard,” or “broad” network so that consumers can better understand the range of providers and facilities available through these plans.

The final rule also adopted other standards to improve consumers’ access to health care providers, including those which will:

  • Provide for continuity of care for up to 90 days when providers are terminated from networks in federal marketplace plans without cause. This provision will allow consumers with certain conditions to continue to see those providers at in-network cost-sharing rates.
  • In 2018, apply cost-sharing for services delivered in in-network settings by certain out-of-network providers to a consumer’s annual out-of-pocket limit. This would be in cases where the consumer does not receive notice at least 48 hours in advance or when the insurer would typically respond to a prior authorization request for care (whichever is longer) indicating that an out-of-network provider could be involved in delivering care and could contribute to certain additional costs. This provision applies in all states.

CMS sets dates for open enrollment and formally expands the role of assisters

On the topic of enrollment in the marketplace, the big news from the final rule involved dates for the fourth open enrollment and beyond. The next two open enrollment periods will be the same as the third open enrollment period (OE3) that concluded January 31. These dates are consistent across the state-based and federal marketplaces:

Open Enrollment Period Coverage Year
November 1, 2016 to January 31, 2017 (OE4) 2017
November 1, 2017 to January 31, 2018 (OE5) 2018
November 1 to December 15 (OE6 and beyond) 2019 and beyond

Based on our work with assisters from across the country, we have recommended that CMS align future open enrollment periods with the tax filing season. While CMS did not adopt that recommendation, we encourage assisters to continue to build and leverage relationships with tax preparers.

Also of note in the final rule is that open enrollment periods for OE6 and beyond will be only a month and a half long. That is half the length of the last open enrollment period. This will require assisters to be even more strategic in how they deal with times of high demand. 

The scope of the work of federally funded navigators was also expanded in the final rule. Starting in 2018, CMS is requiring navigators to play a larger role in helping consumers with post-enrollment issues, such as eligibility appeals and exemptions. We know that many navigators have already been doing this work based on the needs of the consumers they serve, but this formal recognition underscores the importance of providing all navigators with adequate training and resources on these activities.

Families USA will continue to engage with CMS and our partners across the states on these issues and others included in the “Notice of Benefit and Payment Parameters” rule to ensure that the marketplace and participating plans can continue to improve in their ability to meet the needs of consumers for access to high-quality, affordable health coverage and care.

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