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CMS Announces HIX Changes for 2015

 |  By Christopher Cheney  
   March 20, 2014

New 2015 rules for the health insurance exchanges establish a clear and relatively straightforward path to renewing health plans and beneficiary policies. But several payer concerns still remain.

In their "Final 2015 Letter" released Friday for the new public exchanges, federal officials announce a relatively easy framework for health plan and beneficiary policy renewals for 2015, adopt changes related to provider networks, and set a 2015 health plan application timeline that pegs open enrollment to begin Nov. 15.

Health plan executives and state exchange officials alike have anxiously awaited a decision on how the federal Centers for Medicare and Medicaid Services would set 2015 renewal rules. The prospect of requiring all beneficiaries to obtain 2015 coverage through open enrollment had prompted fears of beneficiaries dropping out of the exchanges or switching health plans in large numbers, disrupting the nascent markets for individual and small business health insurance.

In the Final 2015 Letter, CMS states, "Current enrollees in recertified plans will remain enrolled into the new benefit year, as long as those enrollees do not terminate their coverage."

The new rules released Friday also allow insurers operating on the exchanges to keep 2014 carrier and health plan identification numbers for plans recertified for 2015. The insurers' trade association, America's Health Insurance Plans, had predicted a logistical nightmare if new identification numbers were required in 2015. "Changing these IDs would be extremely disruptive both for consumers (in not having the option to remain enrolled in their current QHP) as well as for plans in supporting the electronic file transfer between the Exchange and the plan," AHIP officials said in formal comments submitted to CMS on Feb. 25.

Provider networks

The Final 2015 Letter establishes a new standard to measure provider network adequacy and creates a more stringent standard for the inclusion of essential community providers such as hospitals that serve low-income patients.

"CMS will now be assessing provider networks with a 'reasonable access' standard in order to figure out which networks failed to provide access 'without unreasonable delay,'" says Gregory Hammond, a legal analyst at the Health Reform KnowlEdge Center in Riverview, IL.

For the 2014 plan year, CMS assessed provider network adequacy based on three criteria: carrier accreditation status, a state review that was at least as stringent as reviews required under federal law, and network access plans collected from carriers.

In their formal comments filed Feb. 25, AHIP officials urged CMS not to change the provider network adequacy criteria: "First, the proposed changes are a significant and unnecessary departure from how network adequacy is reviewed today. Second, we are very concerned that such significant changes and rulemaking are being considered so close to the beginning of the application submission process. Third, we believe CMS' approach will be practically difficult—if not impossible—to implement, particularly for the 2015 benefit year." The AHIP officials say developing a provider network "can take upward of a year or more to complete."

In another blow to AHIP's members, the Final 2015 Letter sets a higher standard for the percentage of essential community providers that insurers must include in their provider networks. For 2014, provider networks operating on the exchanges had to include 20% of essential community providers present in the network's geographic area. In 2015, provider networks will be required to include 30% of essential community providers.

In its Feb. 25 comments submitted to federal regulators, AHIP raised several objections to the 30% standard, including the short time frame to adjust to the new standard, the apparent emphasis on network size over other considerations such quality and local market dynamics, and the "troubling" ability of CMS to review payment rates and offers to prove good faith, which could reveal "sensitive competitive information."

More change on 2015 horizon

In a change that adds bite to regulation of the public exchanges, CMS will not be continuing the "good faith enforcement safe harbor" given to health plans in 2014, exposing insurers to possible civil fines.

According to the Final 2015 Letter: "CMS acknowledged the transitional nature of the 2014 benefit year, and agreed not to impose civil money penalties or decertify QHPs for non-compliance with certain Marketplace requirements if the QHP issuer has made good faith efforts to comply with applicable requirements. CMS expects that by 2015, issuers will have gained more experience operating in the [public exchange] environment and/or will be more familiar with the Marketplace requirements."

In the preamble to AHIP's Feb. 25 comments to CMS, Dan Durham, AHIP executive vice president for policy and regulatory affairs, presses regulators to keep the safe harbor policy in place for 2015. "Given the continued focus in 2015 on new regulations, technology, processes, and procedures, we urge CMS to continue to recognize good faith efforts regarding compliance in 2015," he says.

And the Final 2015 Letter is not the final word on rule changes for the public exchanges next year. "Some policies with operational implications in the Draft 2015 Letter to Issuers are not being finalized in this Final 2015 Letter to Issuers, with the intent to continue work to accomplish them," the CMS document states.

A CMS official said Wednesday that one area that remains targeted for possible rule changes is the collection of provider network data. The Final 2015 Letter states: "For future years, CMS is further considering appropriate formats for collection of provider network data, which would both enable CMS to review provider network adequacy and allow for the creation of a search engine function for consumers to find particular providers and provider types on HealthCare.gov."

Mark these dates

While noting "all dates are subject to change," the Final 2015 Letter sets a timeline for key dates for health plan applications to participate in the public exchanges. The milestones include the following:

  • The qualified health plan application submission window is set between May 27 and June 27
  • Final submission of health plan data is set for Sept. 4.
  • Health plans should receive notice of final certification by Oct. 14
  • Open enrollment is set to begin Nov. 15

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Christopher Cheney is the CMO editor at HealthLeaders.

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