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Key Provisions of CMS 2015 Draft Letter to Issuers and OPM Multi-State Plan Program Call Letter
Timothy Jost, in Health Affairs Link to more items from this source
[Guidance Overview]
Feb. 5, 2014

"CMS publishes a Letter to Issuers each year to set out the guidelines for qualified health plans participating in the [federal] exchange for the following year.... The biggest changes in the Letter from 2014 concern network adequacy and access to essential community providers.... CMS intends for 2015 to collect plan provider lists and review them to determine whether providers are available without unreasonable delay.... CMS intends to use its review to develop time and distance or other standards for future network review.... QHPs must include 30 percent of [essential community providers (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... CMS is also tightening its standards for reviewing QHPs for discriminatory benefit design.... The Letter requires greater transparency in drug formularies, including direct access to plan-specific formularies without enrollees having to log on or enter a policy number.... Like CMS, OPM intends to enforce network adequacy standards.... [Multi-State Plan (MSP)] issuers must have in place a process to provide timely exceptions to ensure that consumers who need care from out-of-network providers (because of rare or complex medical conditions or lack of in-network providers in a geographic area) can receive it with reasonable cost-sharing, applying enrollee costs to the in-network out-of-pocket maximum, and protection from balance billing."

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