The CMS has proposed mandating minimum network standards for health plans sold on the federal insurance marketplace in 2017 as part of an effort to handle the broad shift toward narrow provider networks.
The Affordable Care Act requires that all medical plans on the exchanges have enough in-network hospitals and doctors for members so that “all services will be accessible without unreasonable delay.” In addition, ACA-compliant plan networks must update their directories monthly and include at least 30% of essential providers.
However, the 381-page proposed rule released Friday goes further, asking states to establish a quantitative measure to ensure ACA policyholders have sufficient access to healthcare providers. If states don’t choose a standard, the CMS proposed a default setting that would measure network adequacy by maximum travel times or distances to providers. Those minimum criteria would be established at a later date, the agency said.
Other major components of the rule include the open-enrollment period for 2017. It will run from Nov. 1, 2016, through Jan. 31, 2017, according to the proposal. The CMS went with that time period because it overlaps with the annual enrollment periods for Medicare and employer-sponsored coverage.
The CMS also said it was seeking comment and data from stakeholders about the ACA’s special-enrollment policy, which allows people to enroll in coverage outside of the open enrollment if they have a major life event, such as having a child.
Insurers have complained that people abuse this option, hopping on and off exchange coverage based on their health status.
The CMS wants to make health plan shopping easier and proposed more “standardized options” for each metal tier. For example, all 2017 bronze options would have a $6,650 deductible, all 2017 silver plans would have a $3,500 deductible and all 2017 gold plans would have a $1,250 deductible. Currently, deductibles and other cost-sharing mechanisms can vary widely within each metal tier, and this would simplify those options for consumers.
The Obama administration is also looking to entice more people to use the small-business health options program, also known as the SHOP exchanges. Starting Jan. 1, 2017, the CMS proposed that employers would be able to offer all plans across all levels of coverage from one insurance company. By offering multiple plans to an employer, the insurer may be more likely to enroll a greater share of the employer’s group.
On the cost-sharing front, HHS is proposing an out-of-pocket annual limit of $7,150 for individuals, up from $6,850 in 2016, and $14,300 a year for families, which is up from next year’s rate of $13,700.
A summary of the proposed rule can be found on the CMS website. Comments are due by Dec. 21.