Implementing Health Reform. On April 29, 2016, the Centers for Medicare and Medicaid Services posted in the Federal Register and at its Paperwork Reduction Act (PRA) website its final proposal for Transparency in Coverage Reporting for Qualified Health Plans (QHPs). This release is a revised version of a proposal CMS released in August of 2015 and takes into account comments made on that proposal.
Section 1311(e)(3) of the Affordable Care Act provides that the marketplaces:
. . . shall require health plans seeking certification as qualified health plans to submit to the Exchange, the Secretary, the State insurance commissioner, and make available to the public, accurate and timely disclosure of the following information:
(i) Claims payment policies and practices.
(ii) Periodic financial disclosures.
(iii) Data on enrollment.
(iv) Data on disenrollment.
(v) Data on the number of claims that are denied.
(vi) Data on rating practices.
(vii) Information on cost-sharing and payments with respect to any out-of-network coverage.
(viii) Information on enrollee and participant rights under this title.
(ix) Other information as determined appropriate by the Secretary.
ACA section 2715A requires all non-grandfathered health insurers and group health plans to submit these same data to HHS and state insurance commissioners, and to make these data public.
A Delayed And Gradual Implementation Of ACA Transparency Provisions
Although 2715A has been in effect since 2010 and 1311(e)(3) since 2014, HHS has not yet begun to collect the data required by these provisions. Indeed, the administration has stated in earlier guidance that it has no intention of implementing section 2715A until it has undertaken further rulemaking. Moreover, the current data collection only applies to QHPs in the federally facilitated marketplaces (FFMs) and in state-based marketplaces that use the FFM platform. It does not yet include all of the data elements for which data collection is required under section 1311(e)(3).
Indeed, as revised, the proposal does not even actually require QHP insurers to submit any data during 2016, except for identification and contact information. Insurers are given the option of submitting a URL linking to specified information described below, but the URL link only is required as of 2017 for the 2018 open enrollment period. Otherwise, CMS will only display or link to information already available.
Once the program is finally operational, data elements will be submitted to CMS under a separate reporting process from that through which information is submitted for certification. The data will be displayed in a public use file (PUF) rather than on healthcare.gov. CMS reiterates in the PRA notice its intention not to use the data for oversight purposes and not to seek access to data from the EDGE server, where insurers already collect information that could be used for transparency and oversight purposes. In general, CMS will consider submission of information to CMS to meet the requirements that insurers submit the information to the marketplace and their state insurance commissioner and post the information on their websites.
Reporting Requirements
Under the revised proposal, insurers may during 2016, and must during 2017 for the 2018 open enrollment period, provide CMS for display on its transparency website a URL that would link to insurer policies or information regarding:
- Out-of-network liability and balance billing (including information on exceptions for out-of-network liability, as for emergency services);
- How enrollees can submit claims in lieu of a provider if their provider fails to submit a bill;
- Grace periods and pending of claims during grace periods (including notice that enrollees could be ultimately liable for pended claims if they do not catch up on their premiums;
- Retroactive claims denials;
- Recoupment of overpayments by enrollees;
- Medical necessity and prior authorization timeframes and enrollee responsibilities;
- Drug exception (for obtaining non-formulary drugs) timeframes and enrollee responsibilities;
- Explanation of benefit (EOB) forms — what they are, when they are sent, and how they should be read and understood;
- Coordination of benefits; and
- Insurer contact information.
Insurers may link to existing documents, such as their summaries of benefits and coverage, that provide this information. The general public must be able to access the information, however, without having to log on, create a user ID, or enroll in a plan. This information will be collected on an insurer-level, rather than a plan-level basis, but if policies differ by state or market, insurers must provide “applicable material.” If policies are changed, the website should be updated within seven days.
CMS will also display on the transparency website:
- Prior year insurer-level information about insurer premiums, assets, and liabilities, currently reported to and publicly available from the National Association of Insurance Commissioners (NAIC);
- Prior year information on insurer-level enrollment numbers as derived from the FFM;
- Plan-level Unified Rate Review data, already collected and displayed by CMS at healthcare.gov;
- Information displayed on the insurer’s current year summary of benefits and coverage on cost-sharing and out-of-network coverage; and
- Information that CMS already provides on enrollee rights under the ACA.
CMS states in its proposal that during 2017, for the 2018 open enrollment period, it intends to collect and display figures on denied claims for the preceding year, the number and disposition of internal and external appeals, and issuer-level disenrollment numbers. CMS is considering having insurers submit during 2018 claim denial numbers based on CMS-designated reason codes; the number of mental health claims approved versus the total number; and the percentage of medical/surgical (non-mental health) claims approved.
CMS will launch a second phase of data collection in 2019, and may consider collecting plan or product level data; using data collected for oversight purposes; and collecting more granular data on claims, claims payments, and disenrollments, as well as data that might disclose discriminatory practices.
NAIC/State Data Collection Efforts
Fortunately, as mentioned in the CMS release, the NAIC is nearing completion of a market conduct annual statement data collection for health insurers, which should begin in 2017 to collect from health plans much of the data that CMS has failed to collect; the data will be used by state regulators for oversight purposes. Unfortunately, this data will not be available to the public, as the 1311(e)(3) and 2715A data are legally required to be.
from Health Affairs BlogHealth Affairs Blog http://ift.tt/1NOI87o
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