CMS Proposes Improvements for Health Insurance Marketplaces

CMS has announced proposed changes to the 2017 health insurance marketplaces aimed at providing choice and competition for consumers and improvements in consumer experience.

During the first few weeks of the third open enrollment period, there has been some unsettling news. First, co-ops continue to have trouble, with more than half expected to close by the end of the year, and POLITICO reported that the surviving 11 still stand to lose $200 million through the first 9 months of 2015. Then, UnitedHealth Group made the surprising announcement that it was considering pulling out of the health insurance exchanges due to poor performance.

In the midst of all this, CMS has announced proposed improvements to the 2017 marketplaces that are available for comment.

The proposals from CMS seek to provide continued choice and competition for consumers and improve consumer experience both when they shop for a plan and when they use it.

One proposal that CMS is seeking comment on is the requirement that health plans on HealthCare.gov count certain out-of-pocket expenses on unexpected out-of-network services toward the annual out-of-pocket maximum with the intent to reduce surprise bills. The kind of expenses that would count are services performed at an in-network facility when advance notice was not provided. Currently these types of out-of-network charges are usually not counted toward the out-of-pocket maximum.

CMS is also looking to expand the required duties of navigators to help provide assistance to consumers who may not understand their coverage and how it can be used. Additional duties of navigators would include post-enrollment assistance, applying for exemptions through the marketplace, and navigating the transition from coverage to care.

The proposed rule is also seeking comment on a number of proposals, such as:

  • Streamlining direct enrollment and decreasing administrative costs for insurers
  • Keeping the federal Marketplace user fee stable for 2017
  • Recalibrating the risk adjustment formula to provide greater accuracy of payments
  • Open enrollment period for 2018 and beyond

“We look forward to reviewing comments to these proposed rules to make the Marketplaces work even better so that consumers will benefit from choice and competition,” Kevin Counihan, CEO of the Health Insurance Marketplaces, said in a statement.