The Centers for Medicare and Medicaid Services issued its annual proposed rule on 20 November 2015. Therein, the agency summarizes the criteria for health insurance plans which will be sold in the 2017 plan year. On top of the several highly technical insurance disputes, the proposed rule is meant to set up a new policy, which will work to boost network adequacy.

In this NPRM, CMS also announced the enrolment period for 2017, and the plan to increase the beneficiary out-of-pocket for the plan year. The rule also suggests a “continuation of care” policy, which caters to beneficiaries whose provider leaves their network while still undergoing treatment.

At the end of the 2017 open enrollment period, individuals and families can only sign up in ACA Qualified Health Plans if they can prove a “qualifying life event” – something that materially affects their personal situation and entails a change in insurance. This includes a change in job, getting married or divorced, birth of a child, death of a spouse or family member, etc.

CMS also brought a proposal to raise the total allowable cost sharing that a beneficiary can be subjected to. Under this proposal, the total out-of-pocket limit for individual coverage would be $7150, while for family coverage this would be $14300. The 2016 limit stands at $6850 and $13700 respectively. In 2014, these caps were $6350 and $12700.

Among stakeholders, there is the lingering concern that plans sold on the HIEs have provider networks, which are exceedingly narrow. The proposed rule would also boost the federal minimum network adequacy criteria for plans sold in Federal HIEs. Meanwhile for state-run Exchanges, each state would be left to plan and bring up their own network adequacy standards for plans sold there.

The proposal if accepted, authorizes HHS to set up metrics, which define the onset of network adequacy. State HIEs not liable to Federal minimum standard compliance, would have a choice from these metrics and be able to apply them as their own network adequacy standard.

The metrics proposed include: a) accessibility in terms of distance for certain high-utilization specialties, and b) the minimum physician/population ratios for these high-utilization specialties. CMS is also considering setting up a rating system to grade network adequacy for each of the plans mentioned on the website.

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