HHS Releases New Requirements for Health Plans in Federally Facilitated Marketplaces for 2015

UPDATE: Families USA has now released template comments on the 2015 Letter to Issuers in the Federally Facilitated Marketplace (FFM) (the guidance discussed in this blog) for you to use in drafting your own comments. To see Families USA’s completed comments as submitted to HHS, click here.

Yesterday, the Department of Health and Human Services (HHS) released guidance to health insurers that outlines what the agency will require of health plans that want to sell health or stand-alone dental coverage in federally facilitated marketplaces (FFMs) next year. (Partnership marketplaces and federally facilitated marketplaces that conduct plan management functions may also implement these standards, although they have some flexibility in how they do so.)

The guidance letter sets the timeline under which insurers must submit proposed qualified health plans (QHPs) for federally facilitated and partnership marketplaces to be sold in 2015 (with a June 27, 2014, deadline for plans in fully federal marketplaces). It also sets standards for several health plan elements that are important to health care consumers, some of which are described below.
HHS is accepting comments on the guidance until February 25, 2014.

What does the HHS guidance require of health plans?

Provider networks and drug formularies

Direct links to provider directories and drug formularies: The guidance proposes requirements that insurers post up-to-date URLs that link directly to provider directories and drug formularies on marketplace websites. It clarifies that these links should not direct consumers to a website that requires further navigation, a login, or a search for a specific insurance product number in order to find the appropriate directory or formulary.

Network adequacy: For 2014, HHS is relying on state reviews or health plan accreditation to assess whether qualified health plans have adequate provider networks to serve their enrollees. For 2015, however, health plans will be required to directly submit their provider lists to HHS so it can assess whether the plans can provide access to care without unreasonable delay. In addition to these strengthened requirements, the guidance indicates that HHS is considering future federally facilitated marketplace network adequacy requirements that address factors such as a consumer’s travel time and distance to health care providers, along with a searchable provider directory for consumers.

Access to essential community providers: The guidance also strengthens standards for ensuring that essential community providers, those who serve predominantly low-income and medically underserved individuals, are sufficiently included in qualified health plan provider networks. The guidance proposes that plans in the federally facilitated marketplace must contract with at least 30 percent of the essential community providers in their service area. Plans must also make a good faith effort to contract with at least one of each type of essential community provider listed by HHS (Federally Qualified Health Centers, hospitals, Ryan White HIV/AIDS providers, etc.).

Future proposed rules on coverage transitions: The guidance shows that HHS intends to issue a future rule indicating that marketplaces may require insurers to temporarily cover non-formulary drugs or waive step therapy (which requires patients to try less expensive alternative medications before turning to more costly alternatives) or prior authorization requirements during the first 30 days of a consumer’s coverage that starts on January 1 of any year. HHS is also considering policies to ease coverage transitions for other types of care and is seeking comment on such policies.

Plan design: benefits and cost-sharing

Discriminatory benefit design: The guidance proposes a stronger federal review process in federally facilitated marketplaces to ensure that qualified health plans’ benefit designs do not discourage enrollment of people with significant health needs. This review would include an analysis to identify qualified health plans that are outliers when it comes to cost-sharing for specific benefits, as well as prior authorization and step therapy requirements for prescription drugs to identify potentially discriminatory benefit designs. It would also include review of the language that plans submit to explain covered benefits and exclusions to identify discriminatory practices.

Future proposed rules on cost-sharing for primary care: HHS is considering future rules to require all plans (or at least one plan in each metal level per insurer) to cover three primary care visits prior to a consumer meeting a deductible. HHS is encouraging insurers in federally facilitated marketplaces to adopt this policy.

Premium affordability

Premium rate review: For states that comply with federal rate review requirements, HHS will continue to largely rely on state assessments of whether proposed premiums for qualified health plans are justified. However, HHS intends to conduct new “outlier analyses” to identify premiums that are relatively high or low compared to premiums for other qualified health plans in the area and will work with states to determine if outlier plans should or should not be sold through the federally facilitated marketplace.

How can health care advocates weigh in, and how can Families USA help?

The comment period for this guidance is an important opportunity to influence the policies that will determine how consumers will fare in federally facilitated marketplace coverage in 2015. Comments should be submitted to FFEcomments@cms.hhs.gov by Tuesday, February 25. Families USA will release draft comments the week of February 10 to help others weigh in on how to ensure that marketplace plans can meet consumers’ needs. For more information, contact Claire McAndrew (cmcandrew@familiesusa.org) or Lizette Rivera (lrivera@familiesusa.org).