On May 16, 2014, the Centers for Medicare & Medicaid Services (“CMS”) published a final rule entitled “Exchange and Insurance Market Standards for 2015 and Beyond.” The rule, counting over 400 pages, finalizes policies regarding consumer notices, quality reporting and enrollee satisfaction surveys, the Small Business Health Options Program (SHOP), standards for Navigators and other consumers assisters, and policies regarding the premium stabilization programs, among other standards. The key policies are summarized in the CMS fact sheet and include the following:

  • Standardizing notices to improve consumer education and choices when renewing coverage or discontinuing products.
  • Strengthening the prescription drug exceptions process by requiring coverage determinations within 24 hours of the request for enrollees who suffer from life threatening health conditions or when an enrollee is undergoing a current course of treatment using a drug not covered by the plan; health plans must continue to provide a drug throughout duration of the enrollee’s medical issue.
  • Implementing quality standards by requiring insurers to submit data to support the calculation of quality ratings for which the Department of Health and Human Services (“HHS”) will specify the manner in future technical guidance; Marketplaces must display the HHS-calculated quality ratings and enrollee satisfaction survey results in a standardized manner starting in 2016.
  • Providing additional options for SHOP in 2015 by listing conditions under which a SHOP could opt to not implement “employee choice” but instead allow employees to choose one plan if their State Insurance Commissioner believes it is in the best interest of consumers in their State; of note, an Internal Revenue Service (“IRS”) FAQ explains that an arrangement in which an employer does not establish a health plan but instead reimburses employees for premiums they pay for health insurance fails to satisfy the market reforms and may be subject to a $100/day excise tax per applicable employee under section 4980D of the Internal Revenue Code.
  • Strengthening standards for navigators and other assisters by specifying a non-exhaustive list of state requirements that would preempt federal law under the Affordable Care Act.
  • Clarifying premium stabilization policies by raising the ceiling on allowable administrative costs and raising the floor on profits by 2-percentage points in the risk corridors formula to be uniformly applied in all states for 2015; allocating reinsurance contributions to the reinsurance payment pool before administrative expenses and to the Treasury if there is a shortfall in the collection of reinsurance fee; and finalizing various amendments to the medical loss ratio provisions.

Read the final rule and the CMS FAQ on Health Insurance Market Reforms and Marketplace Standards.