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Obama administration proposes sweeping new health plan rules


By Modern Healthcare
Posted: March 15, 2014 - 6:15 pm ET
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The Obama administration issued sweeping new proposed rules (PDF) late Friday affecting provider networks in insurance exchange plans, consumer access to quality information about plans, selection of plans in the small business exchanges, state rules on enrollment navigators, and reinsurance and medical loss ratios for insurers.

The CMS and HHS said the proposed rules and draft standardized notices that issuers would be required to use when renewing or discontinuing plans will help to ensure consumers understand the changes and choices in the individual and group market.

“We are concerned that some enrollees, particularly those with certain complex medical conditions, are having trouble accessing in a timely fashion clinically appropriate prescription drugs,” read a preamble to the proposed rules.

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Healthcare providers and consumer advocacy groups have complained about exchange health plans narrowing their networks to exclude a significant number of hospitals, physicians, clinics, and other providers. Plans say narrowing their networks is necessary to keep premiums affordable. The insurance industry and business groups are likely to view the new proposed rules with concern.

The government said the proposed rules would “encourage improved consumer protections regarding essential community providers, network adequacy, access to needed prescription drugs, and coverage of care during transitions.” While they are mainly aimed at insurers offering plans on the federally operated HealthCare.gov exchange, the rules were written to influence state-run exchanges and insurers in general.

Under the rules, federal exchanges will scrutinize plans offered on the federal exchange to see whether they have enough hospitals and specialists in various fields of practice.

Plans generally would have to contract with at least 30% of essential community providers in their market, including community health centers, HIV/AIDS clinics, and children's hospitals.

The administration also would require plans to provide easy-to-access online information about the doctors in their network and whether they are accepting new patients.

Plans would not be allowed to discriminate against people with significant health needs. The government would be allowed to challenge any plan that requires prior authorization for drugs used to treat a particular condition.

To help consumers shop for plans based on quality, insurers would have to submit data to support the calculation of their quality ratings. Insurance exchanges would be directed to clearly display the HHS-calculated quality ratings and enrollee satisfaction survey results.

For the Small Business Health Options Program, for 2015 the government would align the start of annual employer election periods in all SHOP exchanges with the start of open enrollment in the individual exchanges to minimize confusion and maximize efficiency.

The government is also proposing to limit states' ability to restrict the activities of enrollment navigators and other assisters, who help people sign up for coverage. The new proposal specifies which types of state law provisions applicable to assisters would conflict with federal law.

In allocating reinsurance contributions to stabilize individual market premiums, the government proposes to raise the ceiling on insurers' allowable administrative costs and raise the floor on profits by 2 percentage points in the risk corridors formula. This adjustment would be applied uniformly in all states for 2015 to help with additional transition costs and uncertainty.

The government also proposes various amendments to the medical loss ratio provisions, including standards that would modify the timeframe for which issuers can include their ICD-10 conversion costs in their MLR calculation and account for the special circumstances of issuers during the changes taking place in 2014, such as unanticipated costs due to high call center volume in January 2014. The core requirements of the MLR program, for example that insurers spend 80% to 85% of premiums on health care and quality improvement, are generally not affected by these proposed adjustments.


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