Federal regulators are trying to set expectations and a tentative schedule for public exchange plans in 2015; they're also proposing a new approach to network adequacy and essential community providers, after complaints from consumers and providers in a few markets.
The last date to submit health plans for certification through either the state or federal rate review system will be Sept. 4, which will allow time for multiple rounds of applications and resubmission before certification is finalized Oct. 17, the Center for Consumer Information and Insurance Oversight wrote in a summary of various proposed and final rules.
Regardless of what state they're selling in, insurers may have some new information to submit to the Centers for Medicare & Medicaid Services this summer. Regulators said they're going to be asking for lists of all in-network and out-of-network hospitals, primary care, mental health and oncology providers, and determine whether they offer patients "reasonable access" in their service area.
"If CMS determines that an issuer's network is inadequate under the reasonable access review standard, CMS will notify the issuer of the identified problem area(s) and will consider the issuer's response in assessing whether the issuer has met the regulatory requirement and prior to making the certification or recertification determination," regulators wrote.
CMS regulators said they will share the new data with state regulators doing their own adequacy reviews, and use it to "assist" the "articulation of time and distance or other standards" in future regulations. They're also welcoming ideas on ways to format the data to create a searchable database provider options for consumers.
For essential community providers, CMS regulators are proposing extending the percentage required in a qualified health plan service area from 20 percent with some exceptions to 30 percent and a "good faith" offer to contract with all available Indian health providers and at least one provider from every category, including federally qualified health centers (FQHCs) and HIV/AIDS providers.
For rate reviews next year, CMS will consider data and actuarial justifications and "any recommendations provided to CMS by the applicable state regulator about patterns or practices of excessive or unjustified rate increases and whether or not particular issuers should be excluded from participation in the Marketplace."
And, possibly in 2016 or beyond, CMS will consider "other factors such as rate growth inside and outside the Marketplace."
Insurers raising rates in states without a review system will have to publish a summary and certain parts of their actuarial justifications, either on their website or on Healthcare.gov.
The initial application window for the federal process is May 26 to June 27, with correction notices and resubmissions in July and August and a Sept. 4 deadline for final submission.
However, the regulators caveated, "All dates are subject to change."