On December 2, 2015, CMS is publishing its annual proposed Notice of Benefit and Payment Parameters, which would govern participation in the Affordable Care Act (ACA) Health Insurance Marketplaces for 2017. The wide-ranging rule includes a number of provisions intended to protect consumers enrolled in Marketplace plans, enhance transparency, improve marketplace premium stabilization programs, and make other refinements to Marketplace requirements. Of particular note, the proposed rule would:

  • Require states to establish a provider network adequacy standard for health plans in the federal Marketplace, subject to minimum criteria to be established by CMS.
  • Establish continuity of care protections that require qualified health plan (QHP) issuers to provide prior written notice to enrollees of discontinuation of a provider and, in cases where a provider is terminated without cause, allow an affected enrollee to continue treatment at in-network cost-sharing rates, subject to certain parameters.
  • Allow QHP issuers to offer plans with standardized cost-sharing options to facilitate consumer comparison of plans.
  • Require QHP issuers to count certain out-of-pocket expenses on “surprise” out-of-network services towards an enrollee’s out-of-pocket maximum if the service was performed at an in-network facility and advance notice was not provided (such as in cases where a patient has surgery in an in-network facility but finds out later that the anesthesiologist was not part of the network).
  • Require QHP issuers to track hospital agreements with Patient Safety Organizations (PSOs) and provide an exception to the requirement that a QHP issuer may only contract with a hospital with more than 50 beds if the hospital contracts with a PSO.
  • Make several changes to QHP payment parameters, including recalibrating the risk adjustment formula using most recent data, establishing a lower default risk adjustment charge for small issuers, increasing the default risk adjustment charge, and updating the premium adjustment percentage.
  • Increase plan options for employees in the federal Small Business Health Options Program.
  • Expand Navigators’ duties to include certain post-enrollment functions.

The proposed rule also addresses numerous other policy areas, including, among others: standards for the annual open enrollment period for the individual market for 2017; essential health benefits; acceptance of third-party payments by QHPs; 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; user fees for Federally-facilitated Exchanges; and codification of a new “State-based Exchange on the Federal Platform” model. Comments on the rule will be accepted until December 21, 2015.