Thriving in the Health Insurance Marketplace

As the healthcare industry continues to evolve, the Center for Medicare and Medicaid Services (CMS) has proposed five changes for the Patient Protection and Affordable Care Act.  The proposed changes are focused on: Risk Adjustment, Network Adequacy, Out-of-Pocket Maximums, Standardized Options, and Small Business Health Opens Plan (SHOP).  The proposed changes with Risk Adjustment, CMS has suggested incorporating preventative services into the recreation of plan liability for the risk adjustment models in the 2017 benefit year; which is stated as a benefit since preventative care has shown to be rather costly.  With Network Adequacy, CMS anticipated leveraging the National Association of Insurance Commissioners (NAIC) policy deliberations so that states will select a certain number of metrics listed in the Letter to Issuers.  If they fail to do so, CMS proposed further applications to issuers for Qualified Health Plan certification..  In terms of the Out-Of-Pocket maximum, let’s say a facility is in-network for a patient’s care, but the doctor they are being seen by is not, CMS proposes that there should be a “cost-sharing” clause for non-participating providers to be counted towards the enrollees out-of-pocket maximum.  However, there is an exception if the issuer informs the enrollee ahead of time.  Out of the five proposed changes, CMS understands the out-of-pocket changes will be the most difficult to implement and execute.  Centers for Medicare and Medicaid Services also suggested that plans should be displayed for consumers to compare, based on quality and price, rather than the current cost-sharing structure.  Last but not least, CMS proposed offering a “vertical choice” in addition to their already existing “horizontal choice” presented by the Small Business Health Options Plans.  This will give qualified employees choices for all plans, and of all levels from a single issuer.  Since healthcare is constantly evolving, it might be a good idea to keep these changes in mind to start planning for the future.

Source URL https://www.federalregister.gov/articles/2015/12/02/2015-29884/patient-protection-and-affordable-care-act-hhs-notice-of-benefit-and-payment-parameters-for-2017