May 22, 2014

HHS Issues Exchange Rule for 2015 and Beyond

The Centers for Medicare & Medicaid Services (CMS) has issued a final rule for exchange and insurance market standards for 2015 and beyond. The rule finalizes policies regarding consumer notices, quality reporting and enrollee satisfaction surveys, the Small Business Health Options Program (SHOP), standards for Navigators and other consumer assisters, and policies regarding the premium stabilization programs, among other standards.


Key policies outlined in the final rule include:


  • Requirement that issuers use standardized notices when renewing coverage or discontinuing products
  • Development of an expedited exceptions process for enrollees suffering from a health condition that may seriously jeopardize the enrollee's life, health, or ability to regain maximum function, or when an enrollee is undergoing a current course of treatment using a drug not covered by the plan; health plans must make coverage determinations within no more than 24 hours after receiving the request, and must continue to provide the drug throughout the duration of the enrollee's medical issue
  • Requirement that insurers submit data to support the calculation of quality ratings and that marketplaces display the HHS-calculated quality ratings and enrollee satisfaction survey results starting in 2016
  • Alignment of annual employer election periods in federally-facilitated-SHOPs for plan years beginning in 2015 with the start of open enrollment in the individual market Exchange; lists the conditions under which a SHOP would be permitted to not implement "employee choice" in which employers would allow employees to choose one plan, rather than any health plan within a metal tier, if their State Insurance Commissioner believes it is in the best interest of consumers
  • Identification of a non-exhaustive list of state requirements that would conflict with the federal standards established for assisters and Marketplace assister programs under title I of the Affordable Care Act
  • Clarification of the premium stabilization policies to allow an increase in the ceiling on allowable administrative costs and an increase to the floor on profits by 2-percentage points in the risk corridors formula

Contact Kathy Reep, vice president of financial services, at (407) 841-6230 for more information.