The Department of Health and Human Services (HHS) and Centers for Medicare and Medicaid Services (CMS) announced last Friday, 20 November, their proposed regulations for benefits and actuarial value in 2017.

Proposed regulations of note:

2017 Out-of-Pocket Maximums

  • $7,150 for individual coverage
  • $14,300 for family coverage

2017 Marketplace (Exchange)

  • Enrollment period will have the same timing as 2016: 1 November 2016 – 31 January 2017
  • Changes to auto-enrollment when an individual’s plan is no longer available: they will be enrolled in most similar plan product offered by the same insurer (carrier), rather than in a different metal level (bronze, silver, gold, platinum) in the same product (health, dental, catastrophic).

2017 User Fee

  • Fee insurers (carriers) pay to sell individual policies on the exchange will remain at 3.5% of monthly premium

Network Adequacy Standards

  • Treating certain out-of-network expenses as in-network: Insurers sponsoring exchange plans would have to provide individuals at least 10 days’ notice prior to a procedure at an in-network facility if the individual might receive out-of-network services.  If notice is not provided, the individual would be allowed to count the out-of-network cost sharing against his or her in-network out-of-pocket maximum.
  • Standards for network coverage: The rules would establish provider network adequacy standards for health plans in the federal Marketplace. These standards would cover factors such as consumer travel time and distance to providers. HHS is also considering creating standards for identifying network strength to improve transparency for consumers.
  • Coverage when a provider leaves the network: The rules would impose new continuity-of-care requirements in the federal Marketplace. Insurers would have to provide 30 days’ notice before discontinuing a network provider. If an individual is receiving active treatment, the insurer would have to cover continuing care for up to 90 days or until treatment is completed.

Standardized Plan Options in the Individual Marketplace

Certain plans would be designated as standardized plans on the federal exchange.  The current proposal includes four silver, one bronze and one gold plan. Insurers can choose to offer standardized plans, non-standardized plans or both. The standardized plans would have:

  • Standard deductible amounts
  • Four-tier drug formularies
  • Only one in-network provider tier
  • Some services, such as office visits, urgent care, and generic drugs, not subject to the deductible
  • A preference for copayments over coinsurance

New Model for State/Federal Partnerships

State Marketplaces that use’s technology for eligibility and enrollment will be known as state-based exchanges on the federal platform (SBE-FPs). States will retain primary responsibility for plan management and consumer assistance while using the federal enrollment system, including certain call center services. This model is intended to make the transition easier should additional states decide to move to in the future.

Navigator Responsibilities

The proposed regulations modify the requirements that apply to navigators. Navigators would be required to provide post-enrollment assistance for functions such as Marketplace eligibility appeals, application for exemptions through the Marketplace, and transitioning from coverage to care

Marketplace Enrollment Directly on Insurer’s Websites

The proposed rules request comments on standards that would allow insurers and web-brokers to directly enroll individuals in the Marketplace while remaining on their own website.

Changes to Federally-Facilitated SHOP Plans

HHS proposes a new employee choice option on the SHOP Marketplace for small employers. Employers can currently offer their employees a single plan or the choice of plans within a metal level. Under the new “vertical choice” model, employers would be able to offer employees a choice of all plans across all available levels of coverage from a single insurer.



Parts of this announcement came from Cigna, Informed on Reform

HHS Proposed Notice of Benefit and Payment Parameters for 2017 Fact Sheet

HHS Document for the Federal Register (12/02/2015)

Draft Actuarial Value Calculator

Draft Actuarial Value Calculator Methodology

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