Policy & Regulation News

Summary of Health Insurance Marketplace Final Rule for 2016

By Jacqueline DiChiara

- CMS issued a 476-page final rule to promote improving the overall Health Insurance Marketplace consumer experience by ensuring affordable and accessible coverage options. On February 20, the federal agency released the final rule, Notice of Benefit and Payment Parameters for 2016.

“CMS is working to improve the consumer experience and promote accountability, uniformity, and transparency in private health insurance,” says CMS Administrator Marilyn Tavenner.

CMS identifies areas where states performing plan management functions in the Federally-facilitated Marketplaces (FFMs) contain flexibility to follow an essentially different approach.

Several standards are being finalized, including those related to essential health benefits (EHBs), habilitative services definitions, pediatric services coverage, and prescription drug coverage. In addition, examples of discriminatory plan designs are provided, as well as proposed requirements for essential community providers (ECPS).

  • 74% of Providers See Increased Patient Financial Responsibility
  • Maximizing MIPS Scores Through Chronic Disease Prevention
  • Permanent SGR Repeal, Physician Medicare Fees Overhauled
  • The final rule establishes payment parameters and provisions related to risk adjustment, reinsurance, and risk corridors programs, cost sharing parameters, cost-sharing reductions, and user fees for Federally-facilitated Exchanges.

    “We finalize a 2016 uniform reinsurance contribution rate of $27 annually per enrollee, and the 2016 uniform reinsurance payment parameters — a $90,000 attachment point, a $250,000 reinsurance cap, and a 50 percent coinsurance rate,” CMS states.

    The notice strengthens transparency, accountability, and availability of healthcare information for consumers. Previously announced standards aim for all Americans to have high-quality health insurance.

    With the exception of plan years in the Federally-facilitated Small Business Health Options Programs (FF-SHOPs), CMS states the following policies apply to the certification process for plan years starting in 2016.

    Extended time offered for filing of upcoming deadlines

    The rule finalizes the annual open enrollment dates: Nov. 1, 2015 to Jan. 31, 2016, providing supplemental time to meet the filing deadlines for 2016 rates.

    Accurate, complete published material that is machine-readable

    To help a consumer find a health plan best fitting his or her personalized needs, the rule explains standards for qualified health plan (QHP) issuers to publish current, accurate, and thorough provider formularies and directories within standard, machine-readable formats.

    Due to an investigation of consumer complaints, state regulator/CMS oversight, or the result of an issuer’s own industry-standard internal compliance and risk management program, QHPs may need to correct deficits as per CMS’s post-certification activities.

    Future rulemaking may mean QHP issues in the FFMs may be subject to other or additional requirements for plan years initiated in 2016.

    Consistency and transparency, strengthened public review and comment

    The final rule mandates a uniform timeline to more easily enable public access to information about individual and small group market rate increases for both QHPs and non QHPs.

    Provisions are included for consumer protection against unreasonable rate increases by ensuring rates are more closely reviewed.

    “Under the proposed rule, the issuer would be required to submit the justification by the earlier of the following: the date by which the State requires a proposed CMS-9944-F 116 rate increase to be filed with the State; or the date specified by the Secretary in guidance,” CMS states.

    Wide-spread access to medication, drug cost-sharing

    Premium stabilization programs grant consumers access to affordable healthcare that is high in quality.

    Under the rule, consumer will have better medication access via improvement of the enrollee process of medication request when not included on a plan’s formulary. The standard exception process is also presented in greater detail.

    Also added is a requirement for an external review of an exception request if the initial request is denied by the health plan.

    The rule also explains cost-sharing for drugs obtained through the exceptions process counts within the annual limitation on cost sharing of a plan subject the essential health benefits requirement.

    And, the rule ensures issuers’ formularies are developed based on expert recommendations.

    Oral interpretation services require telephonic interpreters with 150 languages

    All marketplace, QHP issuers, and web brokers are required to provide telephonic interpreter services in a minimum of 150 languages in addition to existing oral interpretation services offered.

    The final rule includes an example of written translations in the languages spoken by whichever is greater — the top 10 limited English proficiency (LEP) groups in the state or the languages spoken by at least 10,000 persons.

    In addition, an example of specific to website content is provided, requiring content to be translated “in each non-English language spoken by an LEP population that reaches 10 percent of the State population.”