News Feature | February 11, 2014

CMS Proposes Tougher Health Exchange Standards

Christine Kern

By Christine Kern, contributing writer

HTO Insurance Definition

CMS has proposed tougher standards for insurers who sell Health Exchanges in 2015

A new proposal by the CMS means insurers who want to offer plans through federal exchanges for 2015 will have to step up their responsibilities to ensure members have access to adequate networks of providers.

According to a proposal detailed in a letter from the CMS, each participating health plan would have to submit a list of all in-network providers and medical facilities covered under a particular plan. CMS will then review them, in conjunction with state regulators, to ensure that there is “reasonable access” to all types of providers.

The Health Affairs Blog points out that the two largest concerns in the proposal are network adequacy and access to essential community providers (ECPs). In 2014, CMS largely relied on plan accreditation and state review to ensure adequate provider networks, but one of the biggest complaints so far has been that provider networks have been too narrow. Thus, for 2015, CMS intends focus on access to hospital systems, mental health providers, oncology providers, and primary care providers in its assessment of plan data, and to use its review to develop time and distance or other standards for future network review.

The new proposal increases the requirements for ECPs and states that QHPs will have to include 30 percent of ECPs in their provider network and offer contracts in good faith to all available Indian health providers in their service area and at least one ECP in each ECP category.

Modern HealthCare reports, according to Timothy Jost, a healthcare expert at Washington and Lee University School of Law, “It looks like they're going to be taking a much more serious look at network adequacy.”

The CMS letter states: “As only one issuer submitted a justification for the 2014 benefit year as a means to satisfy the 20 percent ECP standard, we anticipate that our intended proposal of the 30 percent ECP standard to the 2015 benefit year will be a feasible standard for issuers to satisfy,”

The CMS is also contemplating requiring all exchange plans - or at least one plan at each level of coverage, per insurer - to cover at least three primary-care office visits each year prior to incurring any deductible. To date, the CMS encourages, but does not demand, health plans to provide that coverage. Jost suggested that such a requirement may be a means of enticing younger, healthier individuals into the exchange by guaranteeing access to a certain level of free care even for high-deductible plans.

The CMS is soliciting public feedback on the proposals through Feb. 25, and there will be two review periods during summer 2014 during which insurers will be notified of any deficiencies in their applications and be allowed to submit changes. All signed agreements for approved products must be finalized by Oct. 17, and open enrollment begins Nov. 15, a delay established by the Obama Administration in November 2013, to allow insurers additional time to evaluate the current marketplace and establish more accurately priced products for 2015.

The deadline for submission of 2015 plans would be June 27 for sale during the 2015 enrollment period.

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