CMS finalizes changes to ACA marketplace: 6 things to know

CMS has released a final rule containing standards for health insurers selling coverage through the Affordable Care Act exchanges in 2017.

Here are six things to know about the standards for 2017 and beyond.

1. Surprise bills. Under the rule, beginning with 2018 plans, charges for services provided by an out-of-network ancillary provider in an in-network facility will go toward an enrollee's annual limitation on cost sharing. The purpose of this change is to limit surprise medical bills. However, there is an exception to the requirement if the issuer provides adequate notice to the enrollee that an out-of-network ancillary provider may be providing services and that the enrollee may incur additional costs.

"Our intent in establishing this policy beginning for the 2018 benefit year is to permit us to monitor ongoing efforts by issuers and providers to address the complex issue of surprise out-of-network cost sharing at in-network facilities," said CMS.

2. Network transparency. Beginning in 2017, CMS will implement a rating of each qualified health plan's network coverage. The rating will be available to consumers when shopping for coverage through HealthCare.gov.

3. Risk-adjustment. CMS updated the risk-adjustment formula using more recent data. The benefit year 2017 risk adjustment factors will be updated to reflect claims data for years 2012 through 2014. "To better address the data lag and more accurately account for conditions with high-cost treatments, we will also trend specialty and traditional drug expenditures at separate growth rates from medical expenditures," said CMS. In previous years, CMS had used the same growth rate for drug and medical expenditures.

4. Standardized options. To simplify the shopping experience for consumers, CMS finalized a proposal to designate plans offering the same level of benefits as "standardized options." For benefit year 2017, CMS developed six standardized plan designs, but issuers will not be forced to offer them.

"We recognize that these cost-sharing structures may not be appropriate for all issuers or all markets," said CMS. "We are not requiring issuers to offer standardized options, nor limiting their ability to offer other qualified health plans, and as a result, we do not believe that standardized options will hamper innovation or limit choice."

5. Patient safety. An insurer offering coverage through the marketplaces may only contract with a hospital with more than 50 beds if the hospital either participates with a federally listed patient safety organization or implements "an evidence-based initiative to improve healthcare quality through the collection, management and analysis of patient safety events that reduces all cause preventable harm, prevents hospital readmission or improves care coordination."

6. Annual open enrollment period. For benefit year 2017, the open enrollment period for the individual marketplaces will begin Nov. 1, 2016, and run through Jan. 31, 2017. The enrollment period for the 2018 benefit year will correspond with 2017. Beginning with the 2019 benefit year, the signup period will be shortened to run from Nov. 1 through Dec. 15.

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