The Affordable Care Act (ACA) provides that if a state lacks the authority or is otherwise substantially unable to enforce the ACA's health insurance reform provisions, the Centers for Medicare and Medicaid Services (CMS) shall itself enforce those provisions directly. Currently CMS directly enforces the ACA's insurance market reform provisions in Alabama, Missouri, Oklahoma, Texas, and Wyoming.
On February 5, 2016, CMS released 2017 form and rate filing instructions for insurers in those five states. Insurers providing individual or group health insurance products (other than excepted benefits and grandfathered products) must file their forms with CMS. Forms must be submitted through the Health Insurance Oversight System (HIOS).
The instructions describe which forms must be filed through HIOS for each product (a package of benefits using a particular network type within a service area) and for each of the plans (pairings of a product with a cost-sharing level, provider networks, and service areas) within each product. Instructions are included as to which specific templates and justifications must be filed with qualified health plan (QHP) and non-QHP products. Forms may be filed after April 11, 2016 and must be filed by May 11, 2016, except that forms on student health products and large group products must be filed 60 days prior to marketing.
The instructions list a number of issues that insurers should be careful about:
- Non-grandfathered small group and individual market insurance products must provide coverage substantially equal to the state's essential health benefits (EHB) benchmark coverage (which will be updated for 2017) and may not impose lifetime or dollar limits on these benefits.
- Tobacco use surcharges can only be imposed in the small group market in connection with tobacco-related wellness programs that will offer enrollees a means to escape the surcharge.
- Non-grandfathered coverage must cover preventive services without cost sharing, including at least one means of contraception for each FDA approved category and an exceptions process for women for whom an alternative contraceptive is medically necessary.
- A detailed explanation must be provided when application of the prescription drug class count and non-discrimination tools result in discrepancies for products that must meet EHB standards.
- Age limits for EHB benefits will be flagged as possible discriminatory benefit design problems.
- Routine patient care must be covered for clinical trials for cancer or other life-threatening diseases.
Rate filings for new or renewal rates must be filed for all single-risk-pool (individual and small group) non-grandfathered plans by May 11, 2016. Quarterly updates for small group plans must be filed at least 105 days prior to the effective date of the change. Rates for non-grandfathered student health plans must be filed 60 days before implementation if a rate increase exceeds 10 percent.
Quality Ratings System And Enrollee Satisfaction Survey Guidance
The ACA requires the Department of Health and Human Services (HHS) to develop a quality rating for each marketplace qualified health plan (QHP) product based on quality and price. It also requires HHS to establish an enrollee satisfaction survey to assess enrollee satisfaction with each QHP offered through the marketplaces with more than 500 enrollees in the prior year. HHS has been developing and testing QHP quality and satisfaction rating standards.
The quality and enrollee satisfaction data submitted by QHP insurers is intended to assist consumers in comparing plans, but will also be used by HHS for compliance oversight and can be used by QHP insurers to improve the quality of their product. QHP insurers will first be required to submit quality and enrollee satisfaction data for 2016. The marketplaces will first display this information for consumers to consider in shopping for the 2017 open enrollment period.
HHS released an initial technical guidance on the quality rating system (QRS) and enrollee satisfaction survey process in September of 2015. In late January, 2016, it released an updated version of this guidance with additional information. This guidance covers the QRS and satisfaction survey implementation schedule, marketplace oversight responsibilities, QRS and enrollee survey requirements, the QRS rating methodology, the quality rating information preview process, marketplace display guidelines, and marketing guidelines for QHP quality rating information.
The January update largely repeats the information in the September guidance, but provides additional information in four areas. First, it provides more details as to which enrollees QHPs must include in their reporting unit. QHP insurers are to include all family or adult-only marketplace QHP enrollees, including multi-state plan enrollees and Small Business Health Options Program (SHOP) QHP plan enrollees, regardless of how they enrolled in the QHP. They are not to include child-only plan enrollees or enrollees in QHPs offered outside of the marketplace or non-QHP plans.
Second, the January guidance describes the final 2016 QRS rating methodology. Information will be collected on 43 measures, but only 28 will be used for scoring. These 28 measures will be converted into 14 composite scores, which will be converted in turn into eight domains, three summary indicators, and one global score. The guidance and its appendices describe these measures and the calculation process.
Third, the guidance contains additional information on the quality rating information preview process. QHP insurers will be able to preview information on their ratings and surveys in the late summer of 2016 and discuss issues with CMS.
Finally, the guidance contains additional information on marketplace display guidelines. HealthCare.gov will display the global score for each QHP product type (Preferred Provider Organization, Health Maintenance Organization, Exclusive Provider Organization, or Point-Of-Service Plan) as a star rating, and may display summary indicators. State-based marketplaces that do not use healthcare.gov are also required to display the global score for each QHP product, which will be provided by HHS, but how they do this will depend on their technical capacities. QHP insurers may also use QRS and enrollee satisfaction scores for marketing purposes, but must do so accurately, specifically, and with appropriate disclaimers within specified guidelines.
from Health Affairs Blog http://ift.tt/1PAmejn
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