Proposed rules for 2016 and post individual, small group and exchange marketplace issued

The U.S. Department of Health and Human Services last week issued a proposed rulemaking governing the individual and small group health insurance markets and the state health benefit exchange marketplace for plan year 2016 and later years. Happy holiday reading: comment on the proposed rules (Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2016, CMS-9944-P) is due December 26, 2014.

There’s a lot to digest in the rulemaking with some of the key proposed rules summarized below. As usual, Timothy Jost has taken his customary deep dive into the rulemaking with posts on the Health Affairs blog that can be viewed here and here.

  • Plan issuers must publish up-to-date, (updated at least monthly) accurate, and complete provider directories including information on which providers are accepting new patients, the provider’s location, contact information, specialty, medical group, and any institutional affiliations in a manner that is easily accessible to plan enrollees, prospective enrollees, the State, the Exchange, HHS and OPM. Directories will be considered easily accessible when the general public is able to view all of the current providers for a plan on the plan’s public website through a clearly identifiable link or tab without having to create or access an account or enter a policy number. The general public should be able to easily discern which providers participate in which plan(s) and provider network(s) if the health plan issuer maintains multiple provider networks and the plan(s) and provider network(s) associated with each provider should be clearly identified on the website.
  • For the purposes of the employer shared responsibility mandate, large employer-sponsored plans must meet both minimum actuarial value and minimum standard of benefits. Plans must provide substantial coverage of both inpatient hospital services and physician services.
  • Health plan issuers must establish pharmacy and therapeutics (P&T) committees to ensure plan formularies cover a sufficient number and type of prescription drugs. P&T committee standards that must be met for prescription drug coverage meet prescription drug essential health benefits requirement for individual and small group plans.
  • New special exchange enrollment period for individuals in non-Medicaid expansion states when their household income increases to meet exchange minimum income eligibility standard, i.e. 100 percent of federal poverty.
  • Individual market open enrollment period for plan years 2016 and later: October 1 to December 15.
  • Expansion of special enrollment period to individuals enrolled in non-calendar year individual health insurance coverage when their policy year ends in 2014 to all years.
  • Small employers participating in state exchange Small Business Health Options Programs (SHOP) can elect to offer SHOP coverage to former employees, retirees and also provide required continuation coverage via the SHOP.
  • Exchanges, QHP issuers, and web brokers must provide oral interpretation services to include telephonic interpreters in at least 150 languages.
  • Health plan issuers may optionally count cost sharing for out-of-network services toward annual cost sharing limits.



Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email or call 530-295-1473. 

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Frederick Pilot

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