CMS Proposed Rule to Improve Payment Parameters for 2016
A new focus on transparency, accountability and the availability of information is created by a new CMS proposed rule.
- Healthcare payment provisions will be getting a new focus on affordability and accessibility with a proposed rule from the Centers for Medicare and Medicaid Services (CMS). The rule will establish stronger consumer standard for 2016 that seek to implement several Affordable Care Act (ACA) provisions on payment parameters for issuers and marketplaces. It will build off of previous standards but will 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,” CMS Administrator Marilyn Tavenner said in a press release. “CMS is working to improve the consumer experience and promote accountability, uniformity and transparency in private health insurance.”
The official release from CMS summarizes the proposed rule as follows:
This proposed rule would set forth payment parameters and provisions related to the risk adjustment, reinsurance, and risk corridors programs; cost sharing parameters and cost-sharing reductions; and user fees for Federally-facilitated Exchanges. It would also provide additional standards for the annual open enrollment period for the individual market for benefit years beginning on or after January 1, 2016, essential health benefits, qualified health plans, network adequacy, quality improvement strategies, the Small Business Health Options Program (SHOP), guaranteed availability, guaranteed renewability, minimum essential coverage, the rate review program, the medical loss ratio program and other related topics.
These changes will happen in a number of ways. Premium stabilization programs were established in 2014 under the ACA to ensure stable pricing for individual and small group markets. The new rule will clarify these programs and payment parameters applicable to the 2016 benefit year for these programs including consumer protection provisions.
Under current rules, consumers who do not take action during the open enrollment window are re-enrolled in a similar coverage from the previous year, even if it experiences significant premium increases. In the new, consumers will be defaulted into a lower cost plan.
Improving transparency happens through the provisions to facilitate public access to information about rate increases in the individual and small group markets using a uniform timeline for both Qualified Health Plans (QHPs) and non-QHPs. It will also further protect against unreasonable rate increases in the individual and small group markets.
Other specific features of the new rule include:
• Improved meaningful access standards by requiring all providers to have interpreter services in at least 150 languages
• Streamlining the administration of group coverage provided through SHOP to align regulations with existing market practices.
• Clarifies standards for QHP issuers to publish updated, accurate and complete provider directories.
• Improved ability for enrollees to request access to medications not included on the plans previously.
