CMS targets balanced billing in proposals for new marketplace guidelines
CMS is requesting comment on whether health plans should designate network strength, such as indicating whether a plan has a broad number of doctors or health facilities in the network or not.
As the health insurance marketplace enters its third year, the Centers for Medicare and Medicaid Services is seeking comment on proposed rules governing participation.
To protect consumer access to care, the proposal asks states to establish a provider network adequacy standard for health plans in the federal marketplace, subject to minimum criteria that CMS would establish at a later date, it said.
To reduce surprise costs consumers may face after buying a policy, CMS is seeking comment on a requirement that health plans in the federal marketplace count certain out-of-pocket expenses on unexpected out-of-network services towards a policy holder's annual out-of-pocket maximum. This requirement would kick-in if the service was performed at an in-network facility and advance notice was not provided.
For instance, if a patient who had surgery at an in-network facility finds out later that the anesthesiologist was not part of the health plan's network, cost-sharing charges for that anesthesiologist's services would count toward the out-of-pocket maximum, protecting the patient against additional financial liability, CMS said. Currently, these types of out-of-network cost-sharing charges are generally not counted towards the out-of-pocket maximum.
To make it easier for consumers to compare plans, CMS is proposing to give issuers the choice of offering plans with standardized options such as cost-sharing. Health plans would not be required to issue such plans and could continue to offer other plans with more variable plan designs.
The proposed rule would also increase options for employees in the federal Small Business Health Options Program for plan years beginning in 2017 and beyond. Under current regulations, employers participating in the federal SHOP marketplace can offer their employees either one health plan and/or one dental plan, or all health and dental plans across one metal level, or actuarial value, for dental plans.
Under the proposal, employers would be able to offer all plans across all levels of coverage from one insurance company.
Recognizing that enrolled consumers may still need assistance in understanding and using their coverage, the proposed rule seeks comment on expanding the required duties of Navigators. The expanded duties would include marketplace eligibility appeals, applying for exemptions, and making the transition from coverage to care.
"This proposal is a step forward in engaging and empowering consumers with the resources they need to understand how to use their coverage," CMS said.
The rule also solicits comments on improvements to the premium stabilization programs including: streamlining direct enrollment so that customers can more easily use websites of agents and brokers, decreasing administrative costs for issuers; keeping the federal marketplace user fee stable for 2017; discussing options on transitioning consumers more smoothly from marketplace coverage to Medicare, so that elderly, often higher-risk consumers, move from the marketplace risk pool to Medicare; recalibrating the risk adjustment formula using most recent data to provide greater accuracy of payments; seeking comment on improvements to the child age rating curve to reflect risk more accurately, so that premiums can be more accurately priced; and seeking comment on the open enrollment period for 2018 and beyond.
Twitter: @SusanJMorse
