Health Insurance Report™ helps you track and analyze legal, legislative, and regulatory developments affecting the health-insurance industry throughout implementation of the Affordable Care Act...
By Sara Hansard
Feb. 20 — The CMS Feb. 20 issued the final Notice of Benefit and Payment Parameters for 2016 (CMS-9944-F; RIN 0938-AS19) and the final 2016 Letter to Issuers in the Federally-facilitated Marketplaces covering a wide range of regulations governing ACA marketplaces.
The final benefit and payment parameters regulation generally takes effect 60 days from publication in the Federal Register, which is slated for Feb. 27. The annual letter to issuers provides additional guidance on standards for plans participating in the federal ACA marketplace, a Centers for Medicare & Medicaid Services release said.
The benefit and payment parameters rule finalizes the annual Affordable Care Act open enrollment period for 2016 as the three-month period from Nov. 1, 2015, through Jan. 31, 2016. The final rule “clarifies standards for qualified health plan (QHP) issuers to publish up-to-date, accurate, and complete provider directories and formularies,” according to the CMS release. The proposed rule was issued in November 2014.
The final rule includes provisions to facilitate public access to information about rate increases in the individual and small group markets for both QHPs and non-QHPs using a uniform timeline, the release said. It also includes provisions “to further protect consumers against unreasonable rate increases by ensuring more rates are subject to review,” it said.
Under an earlier Health and Human Services Department rule, issuers of individual or small group plans that took effect after enactment of the ACA who seek increases of 10 percent or more, or above a threshold established by some states, are required to publicly disclose the proposed increases and the justification for them, and the increases are reviewed by state or federal regulators to determine whether they are unreasonable. The federal government doesn't have authority to disapprove rates, but some states do.
According to a fact sheet, the final rule changes the review trigger for rates filed beginning in 2016 for coverage effective on or after Jan. 1, 2017. Rate increases will be subject to review when a plan within a product has an increase that meets or exceeds the threshold. Currently the HHS determines whether the increases must be reviewed at the product level, such as for an issuer's individual market preferred provider organization product, which could include plans at many levels. An example of a plan would be an issuer's particular silver-tier plan.
The final rule includes new provisions and modifications to implement premium stabilization, or risk adjustment, programs authorized by the ACA, as well as the key payment parameters for the 2016 benefit year.
The fact sheet said that if in the last year of the risk corridors program collections have exceeded payments, “we will implement an adjustment to the profit floor and administrative cost ceiling to increase risk corridors payments for eligible issuers for benefit year 2016. We reiterate our previous guidance that in the unlikely event that risk corridors collections, including any potential carryover from prior years, are insufficient to make risk corridors payments for the 2016 program year, HHS will use other sources of funding for the risk corridors payments, subject to the availability of appropriations.”
Republican lawmakers have attacked the risk corridors program as a “bailout” for insurers, and President Barack Obama Dec. 16 signed an appropriations bill (H.R. 83) blocking the payments for fiscal 2015.
The fact sheet also said the final rule allows issuers to use a pharmacy and therapeutics committee system to design drug formularies that “cover a range of drugs in a broad distribution of therapeutic categories and classes, and provide access to drugs that are included in broadly accepted treatment guidelines.” Patient advocacy groups had complained that the previous rule for prescription drug coverage effectively excluded drugs many patients needed.
The rule provides that states may select new benchmark plans for 2017 based on plans available in 2014.
It also seeks to streamline the administration of group coverage provided through the Small Business Health Options Program “and to align SHOP regulations with existing market practices,” the release said.
To contact the reporter on this story: Sara Hansard in Washington at firstname.lastname@example.org
To contact the editor responsible for this story: Janey Cohen at email@example.com
The final 2016 Letter to Issuers in the Federally-facilitated Marketplaces and a fact sheet on the notice of benefit and payment parameters are available in HealthDocs™.
All Bloomberg BNA treatises are available on standing order, which ensures you will always receive the most current edition of the book or supplement of the title you have ordered from Bloomberg BNA’s book division. As soon as a new supplement or edition is published (usually annually) for a title you’ve previously purchased and requested to be placed on standing order, we’ll ship it to you to review for 30 days without any obligation. During this period, you can either (a) honor the invoice and receive a 5% discount (in addition to any other discounts you may qualify for) off the then-current price of the update, plus shipping and handling or (b) return the book(s), in which case, your invoice will be cancelled upon receipt of the book(s). Call us for a prepaid UPS label for your return. It’s as simple and easy as that. Most importantly, standing orders mean you will never have to worry about the timeliness of the information you’re relying on. And, you may discontinue standing orders at any time by contacting us at 1.800.960.1220 or by sending an email to firstname.lastname@example.org.
Put me on standing order at a 5% discount off list price of all future updates, in addition to any other discounts I may quality for. (Returnable within 30 days.)
Notify me when updates are available (No standing order will be created).
This Bloomberg BNA report is available on standing order, which ensures you will all receive the latest edition. This report is updated annually and we will send you the latest edition once it has been published. By signing up for standing order you will never have to worry about the timeliness of the information you need. And, you may discontinue standing orders at any time by contacting us at 1.800.372.1033, option 5, or by sending us an email to email@example.com.
Put me on standing order
Notify me when new releases are available (no standing order will be created)