Health & Welfare Plans Newsletter

BULLETIN
Supplement to
November 20, 2015

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[Official Guidance]

Text of HHS Notice of Benefit and Payment Parameters for 2017
381 pages. "This proposed rule sets forth payment parameters and provisions related to the risk adjustment, reinsurance, and risk corridors programs; cost sharing parameters and cost-sharing reductions; and user fees for Federally-facilitated Exchanges. It also provides additional standards for the annual open enrollment period for the individual market for the 2017 benefit year; essential health benefits; cost-sharing requirements; qualified health plans; updated standards for Exchange consumer assistance programs; network adequacy; patient safety standards; the Small Business Health Options Program; stand-alone dental plans; acceptance of third-party payments by qualified health plans; the definitions of large employer and small employer; fair health insurance premiums; guaranteed availability; student health insurance coverage; the rate review program; the medical loss ratio program; eligibility and enrollment; exemptions and appeals; and other related topics....

"We propose to codify a new Exchange model -- the State-based Exchange on the Federal platform (SBE-FP). This model would enable State-based Exchanges (SBEs) to execute certain processes using the Federal eligibility and enrollment infrastructure.... We also propose a number of incremental amendments that we believe will improve the stability of the Exchanges while improving the choices available to consumers and supporting consumers' ability to make informed choices when purchasing health insurance. These include the introduction of 'standardized options' in the individual market, which will improve competition and consumer transparency....

"If any reinsurance contribution amounts remain after calculating reinsurance payments for the 2016 benefit year (including after HHS would increase the coinsurance rate to 100 percent for the 2016 benefit year), we propose to lower the 2016 attachment point of $90,000 to pay out any remaining contribution amounts for the 2016 benefit year. We also propose several changes to the risk corridors program for 2015 and 2016....

"For consumers purchasing coverage through the Small Business Health Options Program (SHOP), we propose a new 'vertical choice' model for Federally-facilitated SHOPs for plan years beginning on or after January 1, 2017, under which employers would be able to offer qualified employees a choice of all plans across all available levels of coverage from a single issuer." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])  

[Guidance Overview]

Text of CMS Draft 2017 Actuarial Value Calculator Methodology (PDF)
28 pages. "The first part of this document provides background that includes an overview of the regulation that allows HHS to make updates to the AV Calculator as well as the updates that are incorporated into the draft 2017 AV Calculator. For the second part of the document, we provide a detailed description of the development of the standard population and the AV Calculator methodology. The first section details the data and methods used in constructing the continuance tables that are used to calculate AV in combination with the user inputs. The second section describes the AV Calculator interface and the calculation of actuarial value based on the interface and the continuance tables. The draft 2017 AV Calculator is [available online as a Microsoft Excel spreadsheet]." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])  

[Guidance Overview]

Text of CMS Fact Sheet: Proposed HHS Notice of Benefit and Payment Parameters for 2017 (PDF)
5 pages. "Some of the policies in today's proposed rule include: ... Risk Adjustment Model Recalibration ... Small Issuer Rule for Default Risk Adjustment Charge ... Default Risk Adjustment Charge ... FFM User Fee for 2017 ... Premium Adjustment Percentage ... Annual Limitation on Cost Sharing ... Student Health Insurance Plans ... Rate Review ... Standardized Options ... Improving Product Value ... Network Adequacy (Minimum Threshold) ... SHOP ... Direct Enrollment Enhancements, Agent and Broker Enforcement, and Standards for HHS-Approved Vendors of FFM Training for Agents and Brokers." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])  

[Guidance Overview]

CMS Proposes Improvements for the 2017 Marketplace
A press release issued by CMS: "To protect consumer access to health care providers and delivery organizations, the proposal asks states to establish a provider network adequacy standard for health plans in the federal Marketplace.... CMS is proposing to give issuers the choice of offering plans with standardized options such as cost-sharing.... CMS is seeking comment on a requirement that health plans in the federal Marketplace count certain out-of-pocket expenses on unexpected out-of-network services towards a policy holder's annual out-of-pocket maximum, if the service was performed at an in-network facility and advance notice was not provided.... The proposed rule would also increase options for employees in the federal Small Business Health Options Program (SHOP) for plan years beginning in 2017 and beyond." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])  

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