Federal regulators are starting to finalize simmering ideas for public exchanges and also responding to consumer concerns, outlining a new quality rating system and proposals covering everything from narrow networks to loss ratios.
In proposed rules and guidance covering a range of exchange and insurance policies, the Centers for Medicare & Medicaid Services laid out tentative regulations for its quality reporting and enrollee satisfaction program, plans for previously-delayed small business exchange functions, protections for navigators and consumer assisters, 2015 premium stabilization policies and adjustments to this year's medical loss radio -- among other things.
Quality ratings
Of all the proposals, the quality rating system has some of the most potential to impact sales of health plans. It also mirrors regulators goals in the Medicare Advantage program to weed out underperforming plans by offering consumers clear signals.
Next year, CMS is proposing to gather product-level data from insurers to beta-test the process,starting with data from the first year the plans are available and then validated data thereafter, with the goal of having quality ratings displayed for all exchange plans for the 2017 plan year.
For consumers, the ratings will be presented as a Medicare Advantage-style five star system, although the methodology for the ratings are currently still in development. CMS regulators will be proposing that as well as details on quality measure specifics and data validation process in guidance later this year. What CMS has finalized is that insurers will have to hire independent third parties to validate the data.
A companion to the rating system, enrollee satisfaction surveys, would start around the same time, or perhaps earlier.
Exchanges will eventually display information on past enrollees satisfaction for plans with more than 500 members, and the data would also be incorporated into quality ratings, CMS regulators wrote. States could choose to display data from 2015 beta-surveys before or after 2016.
Based on the Consumer Assessment of Health Providers and Systems Health Plan 5.0 Medicaid survey, the satisfaction survey will be collected by federally-approved vendors from enrollees across both different products and benefit metal tiers starting in 2015.
Health plans will be able to use both quality ratings and enrollee survey data as part of their marketing, and those selling exchange plans in California may already be getting familiar with the ratings in the individual and small group market. Covered California was the first state exchange to offer quality ratings with an early stage ranking system unveiled earlier this year, midway through open enrollment.
MLR
In other regulatory changes CMS is proposing and promulgating, insurers have some new factors for their medical loss ratios.
CMS is amending the transitional MLR issued last November to account for the one-year delay of ICD-10 and for exchange problems.
Insurers can claim up to 0.3 percent of premiums for ICD-10 conversion costs for 2014, just like in 2012 and 2013, regulators wrote. Insurers participating in state or federally-run exchanges can also use a 1.0004 percent increase in claims and quality improvement costs for their entire individual and small group business lines, whether sold on or off exchanges.
Patient access concerns
In other policies, CMS is responding to several sources of concern and discontent among patient advocates.
Under essential health benefit final rules, insurers have to allow enrollees to request and access "clinically appropriate" drugs not covered by a plan's formulary. But whether or not new consumers are able to do that has been the subject of some confusion and dispute, regulators said.
"We are concerned that some enrollees, particularly those with certain complex medical conditions, are having trouble accessing in a timely fashion clinically appropriate prescription drugs, such as prescription drugs that are combination drugs not covered by their plans' formularies," CMS regulators wrote.
They're now considering amending formulary exception standards "to require that these processes can be expedited when necessary based on exigent circumstances, such as when an enrollee is suffering from a serious health condition or an enrollee is in a current course of treatment using a non-formulary drug."
As an example, "we could specify that an issuer render decisions regarding formulary exceptions requests within 24 hours following the issuers' receipt of the exceptions requests," regulators wrote.
In a letter to insurers, separate from the proposed rules, CMS regulators are also planning to go ahead with new network adequacy guidelines in insurance exchanges.
In the 2015 plan year, qualified health plan provider networks will need to have at least at least 30 percent of available essential community providers in a service area, as well as all available Indian health providers and at least one essential community provider in each service area county from the categories of federally-qualified health clinics, Ryan White AIDS providers, hospitals and specialized providers, such as hemophilia treatment clinics.