Health & Welfare Plans Newsletter

December 17, 2016 logo logo
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[Official Guidance]

Text of CMS 2018 Letter to Issuers in the Federally-facilitated Marketplaces (PDF)
85 pages. "This Letter provides issuers seeking to offer qualified health plans (QHPs), including stand-alone dental plans (SADPs), in the Federally-facilitated Marketplaces (FFMs) or the Federally-facilitated Small Business Health Options Programs (FF-SHOPs) with operational and technical guidance to help them successfully participate in any such Marketplace in 2018." Topics include: [1] Certification process for QHPs, [2] QHP and SADP Certification Standards, [3] Consumer support tools and public information, [4] QHP performance and oversight, [5] FF-SHOPs, and [6] Consumer support and related issues.
Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS]

[Official Guidance]

Text of CMS Final Regs: ACA Benefit and Payment Parameters for 2018; Amendments to Special Enrollment Periods and the Consumer Operated and Oriented Plan Program
465 pages. "This final rule sets forth payment parameters and provisions related to the risk adjustment program; cost-sharing parameters and cost-sharing reductions; and user fees for Federally-facilitated Exchanges and State-based Exchanges on the Federal platform. It also provides additional guidance relating to standardized options; qualified health plans; consumer assistance tools; network adequacy; the Small Business Health Options Programs; stand-alone dental plans; fair health insurance premiums; guaranteed availability and guaranteed renewability; the medical loss ratio program; eligibility and enrollment; appeals; consumer-operated and oriented plans; special enrollment periods; and other related topics.... These regulations are effective January 17, 2017."
Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS]

[Official Guidance]

Text of CMS Technical FAQs: Second Lowest Cost Silver Plan (PDF)
5 pages, dated Dec. 16, 2016. "This document covers some of the frequent questions and, in the process, explains why the SLCSP returned by the Marketplace may not match what estimator tools return in certain scenarios.... The answers [in this document] apply to plan year 2017 ... [1] How do a QHP's rules about which family members may be covered together under a policy affect the SLCSP determination? ... [2] For states using the Federal platform for eligibility and enrollment, who is the subscriber for purposes of finding the SLCSP? ... [3] How are child-only and adult-only plans incorporated into the SLCSP determination? ... [4] At what geographic level is SLCSP determined? ... [5] If consumers meet the income, tax filing, and other coverage requirements for the premium tax credit, will they receive a premium tax credit (or advance payments)? ... [6] How is essential health benefits (EHB) percent of premium used when determining SLCSP? ... [7] At what point in time is the SLCSP determined? ... [8] Can I use the QHP landscape to determine SLCSP?"
Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS]

[Guidance Overview]

CMS Fact Sheet: Final HHS Notice of Benefit and Payment Parameters for 2018
"[CMS is] finalizing

  • the incorporation of partial year adjustment factors in the adult risk adjustment model to address feedback that the existing model under predicts claims costs for enrollees who are enrolled for only part of the year....
  • the use of prescription drug utilization data to improve the predictive ability of our risk adjustment models beginning for the 2018 benefit year....
  • the creation of a pool for high-cost enrollees where an adjustment to issuers' transfers would fund 60 percent of an issuer's costs for individuals with claims above $1 million....
  • an adjustment to reduce the calculation of statewide average premium used in the risk adjustment transfer formula by 14 percent to account for fixed administrative costs beginning for the 2018 benefit year....
  • a Federally-facilitated Marketplaces (FFM) user fee rate of 3.5 percent of premiums for the 2018 benefit year. This user fee rate is the same as the rate for each year from 2014 through 2017 benefit years....
  • a maximum annual limitation on cost sharing for 2018 of $7,350 for individual coverage and $14,700 for family coverage....
  • an allowance for a broader de minimis range for the actuarial value of bronze plans when the plan covers at least one major service, other than preventive services, before application of the deductible or is a high deductible health plan (HDHP)....
  • updated standardized options [for 2018], based on [an] analysis of enrollment-weighted 2016 individual market FFM QHP data and also SBM-FP QHP data....
  • three sets of standardized options and selecting one standardized option at each level of coverage for each State based on that State's cost-sharing requirements....
  • one high-deductible health plan option at the bronze level of coverage that issuers may choose to offer as long as the plan does not conflict with State cost-sharing laws....
  • a number of additional consumer protections around the direct enrollment channel, though which web-brokers and issuers may assist consumers with enrollments through an Exchange using a non-Exchange website....
  • updates to the child age rating structure to better reflect the health risk of children and to provide a more gradual transition when individuals move from age 20 to 21....
  • several changes to the guaranteed renewability regulations that would address instances where issuers may inadvertently trigger a market withdrawal and 5-year ban on market reentry....
  • amendments to the medical loss ratio (MLR) provisions that will allow issuers the option to defer reporting of policies newly issued with a full 12 months of experience (rather than only policies newly issued and with less than 12 months of experience) in that MLR reporting year, and the option to limit the total rebate liability payable with respect to a given calendar year.

Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS]

[Guidance Overview]

CMS Final List of Key Dates for Calendar Year 2017 (PDF)
"This document summarizes key dates for calendar year 2017 regarding some activities and policies that are outlined in other documents."
Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS]

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David Rhett Baker, J.D., Editor and Publisher
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BenefitsLink Health & Welfare Plans Newsletter, ISSN no. 1536-9595. Copyright 2016, Inc. All materials contained in this newsletter are protected by United States copyright law and may not be reproduced, distributed, transmitted, displayed, published or broadcast without the prior written permission of, Inc., or in the case of third party materials, the owner of that content. You may not alter or remove any trademark, copyright or other notice from copies of the content.

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