CMS has published its annual Notice of Benefit and Payment Parameters, which governs participation in the Affordable Care Act (ACA) Health Insurance Marketplaces for 2017.  The sweeping rule addresses protection of consumers enrolled in Marketplace plans, network adequacy, marketplace premium stabilization programs, and various other refinements to Marketplace requirements.  Major provisions of the rule include the following:

  • CMS makes several changes to qualified health plan (QHP) payment parameters, including recalibrating the risk adjustment formula using most recent data and establishing separate growth rates for traditional drugs, specialty drugs, and medical/surgical expenditures; establishing a lower default risk adjustment charge for small issuers; increasing the default risk adjustment charge; updating the premium adjustment percentage; and setting the 2017 maximum annual limitation on cost sharing at $7,150 for individual coverage and $14,300 for family coverage.
  • To limit “surprise” bills to consumers when out-of-network services are performed at an in-network facility (i.e., the patient has surgery in an in-network facility but later learns later that the anesthesiologist was not part of the network), the final rule requires QHP issuers to count such out-of-pocket expenses towards an enrollee’s out-of-pocket maximum unless notification requirements are met (beginning in 2018).
  • The rule establishes continuity of care protections that require 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.
  • CMS plans to include ratings on related to each QHP’s relative network coverage starting in 2017. CMS did not adopt its proposal to establish a minimum quantitative state network adequacy measurement.
  • The final rule allows QHP issuers to offer plans with standardized cost-sharing options to facilitate consumer comparison of plans.
  • The final rule requires QHP issuers to verify that contracted hospitals with more than 50 beds either (1) work with a Patient Safety Organization, or (2) implement an evidence-based initiative to improve health care quality through data collection and analysis of patient safety events to reduce all cause preventable harm, prevent hospital readmissions, and improve care coordination.
  • Under the final rule, for coverage in 2017 and 2018, open enrollment will run from November 1 of the previous year through January 31 of the coverage year. For coverage in 2019 and beyond, open enrollment will run from November 1 through December 15 of the year preceding coverage.

The final rule also addresses numerous other policy areas, including: Navigators’ post-enrollment functions;  Small Business Health Options Program plans; third-party cost-sharing payments; 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.

CMS also released a variety of guidance documents in connection with the final rule, including: