Health Insurers Concerned About Additional Rules for 2015 Federal Marketplace Plans

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By Sara Hansard  

March 3 --Significant problems remain for health plans that are enrolling people in coverage under the Affordable Care Act, and health insurers are “very concerned” that a Department of Health and Human Services proposal for 2015 rules contains “numerous suggestions” of additional requirements, America's Health Insurance Plans (AHIP) said in comments filed Feb. 25.

In its letter signed by Dan Durham, executive vice president, policy and regulatory affairs, AHIP pointed to the HHS's proposal to add more requirements for network adequacy, prescription drug benefits and primary care office visits, among other things, that were included in a Draft 2015 Letter to Issuers in the Federally-facilitated Marketplaces (FFMs) released Feb. 4 by the Centers for Medicare & Medicaid Services .

“That CMS would consider rulemaking in all of these areas--when the application process for 2015 is just a few months away--is of great concern,” AHIP said.

AHIP said its long-standing concerns remain about whether plans sold through the marketplaces will be affordable for the crucial demographic market of young, healthy people. “We remain concerned that adverse selection and unnecessarily high costs will occur in the absence of broad market participation,” AHIP said. Adverse selection means a disproportionately high share of high-cost people with medical problems enroll in the marketplace plans, leading to spiraling unaffordable costs.

Plans Still Making Manual Corrections

Although progress has been made in improving the functioning of the federal enrollment website, which had numerous problems early in open enrollment, which began Oct. 1, 2013, AHIP said health plans are continuing to dedicate “significant resources” to making manual corrections for duplicate enrollments and missing enrollment forms, as well as special enrollment periods that have been granted by the Obama administration to compensate for errors made by the FFMs. Open enrollment ends March 31.

AHIP urged the CMS to “continue to recognize good faith efforts regarding compliance through the 2015 year.” Final rules issued by the CMS for 2014 on the marketplaces, the Small Business Health Options Program (SHOP) and eligibility appeals acknowledged the transitional nature of the 2014 benefit year and didn't impose civil monetary penalties or decertification for noncompliance efforts, AHIP said, urging the CMS to extend that treatment.

In its Feb. 25 letter, the Choice and Competition Coalition, which represents business groups, health-care providers and health insurance groups, asked that an ACA requirement that employees have a choice of health insurance options be delayed beyond 2015. The “employee choice” option in the SHOP marketplaces was delayed for a year until 2015 by the HHS .

“Problems associated with the rollout of the FFMs and State-based exchanges have confirmed our view that achieving basic functionality should be given priority over more complex functionality such as an employee-choice model,” the coalition said. “A functional model would include the ability for SHOP to process enrollments for employers and communicate them to issuers in an automated manner,” the group said.

The coalition includes the National Retail Federation, the U.S. Chamber of Commerce, the Federation of American Hospitals, the Pharmaceutical Research and Manufacturers of America, AHIP, the Blue Cross and Blue Shield Association, the National Association of Health Underwriters and the National Association of Insurance and Financial Advisors.

Hospital Comments

In its Feb. 25 letter, the American Hospital Association (AHA) recommended that the CMS provide specific requirements on the criteria it would use to determine whether plan networks are reasonable. The criteria might include time or distance to network providers of essential health benefits, average wait times to get appointments and the availability of network providers in accepting new patients, it said. The letter was signed by Linda Fishman, senior vice president, public policy analysis and development.

To keep costs down, many marketplace plans have limited provider networks that they cover or for which they give enrollees preferential cost-sharing rates, which has drawn criticism. The CMS draft letter proposed that health plans meet stricter network standards.

“It is important to ensure that enrollees have access to a selection of high-quality providers in or near to their communities, while not inhibiting care coordination and the growth of integrated care systems.”  


--American Hospital Association

The AHA, which represents nearly 5,000 hospitals and health-care organizations, supported a proposal in the draft letter requiring that a minimum of 30 percent of “essential community providers” in a plan's service area participate in the provider network.

“It is important to ensure that enrollees have access to a selection of high-quality providers in or near to their communities, while not inhibiting care coordination and the growth of integrated care systems,” the AHA said.

In its Feb. 25 letter, the Federation of American Hospitals (FAH) criticized the CMS's proposal to no longer collect network access plans as part of its evaluation of network adequacy in favor of a plan using a “reasonable access” review standard.

“Network access plans provide a frame of reference for CMS to evaluate network adequacy, and should be used by CMS as a basis for meaningful review of network adequacy,” said the FAH letter, signed by Charles Kahn III, president and chief executive officer.

'Robust Standards for Network Adequacy.'

Families USA, a group that has advocated for the ACA, said in its Feb. 11 letter, “Robust standards for network adequacy, access to essential community providers, rate considerations, non-discrimination in benefit design” and other issues are necessary to ensure that consumers' needs are met.

Families USA called for requiring all states, including those with state-run marketplaces, as well as those operating marketplaces in partnership with the federal government, to enforce standards for marketplace plans--including those for network adequacy and essential community providers--“that are no less stringent than those applied to the FFM.”

In its Feb. 25 letter, Consumers Union also said the draft letter “should be a strong floor for all Marketplace policies.” The group's letter was signed by Betsy Imholz, special projects director; Lisa McGiffert, project manager, Safe Patient Project; Lynn Quincy, associate director, health reform policy; and Julie Silas, senior attorney.

Consumers Union called for the CMS to communicate with issuers and regulators about whether actuarial justifications used by issuers are “questionable.” That would give issuers a chance to revise their bids downward, which happened in states in 2014, Consumers Union said.

“Consumers are paying an ever increasing share of health care costs and are heavily weighted down by health care and insurance affordability concerns,” Consumers Union said.

In its Feb. 25 comment letter, the Center on Budget and Policy Priorities (CBPP) asked the CMS to provide preliminary plan information to the public before Oct. 17, when the FFM is to certify the plans that will be offered in the federal marketplace for 2015.

“This would help reduce confusion or misinformation about marketplace plan options,” said the CBPP letter, signed by senior policy analysts Sarah Lueck, Dave Chandra and Shelby Gonzales, and Edwin Park, vice president for health policy.

AIDS Institute's 'Deep Dissatisfaction.'

In its Feb. 24 letter, the AIDS Institute expressed “deep dissatisfaction that CMS has not yet promulgated a regulation or provided guidance on how the critical patient non-discrimination provisions in the ACA are to be enforced.”

In a recent communication to the human immunodeficiency virus (HIV) community, the CMS wrote that concerns should be taken to state insurance departments or marketplace call centers, according to the letter, signed by Carl Schmid, deputy executive director.

“This complete disregard for the strict federal anti-discrimination protections found in Section 1557 of the ACA is very troubling, and can potentially undermine the success of the ACA and patients' ability to access quality and affordable health care,” the letter said.

A class action lawsuit was filed Feb. 20 against Blue Cross and Blue Shield of Louisiana and two other health insurers in the state, charging that they are violating sections 1557(a) and 1311(c) of the ACA and Louisiana state law by discriminating against people with HIV who are qualified for premium assistance from the federally funded Ryan White program (East v. Blue Cross and Blue Shield of La.,M.D. La., No. 14-115, filed 2/20/14; .


To contact the reporter on this story: Sara Hansard in Washington at

To contact the editor responsible for this story: Janey Cohen at

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