The Centers for Medicare and Medicaid Services (CMS) published a Final Rule intended to stabilize the individual and small group insurance markets on April 18, 2017. Reflecting the urgent need to address the uncertainty afflicting the markets, CMS advanced the rule from proposed to final form in just two short months despite receiving more than 4,000 comments. Not surprisingly, the Final Rule does not differ substantially from its proposed version. The critical questions are whether the Final Rule can produce stability in the markets and prompt issuers to offer products on the Exchanges established under the Affordable Care Act (ACA) and whether a significant relaxation in the rules concerning network adequacy and the inclusion of essential community providers (ECPs) ensure that the right mix of hospitals, physicians and other providers are available to those purchasing insurance products on the Exchanges.
The Final Rule amends standards relating to special enrollment periods, the timing of open enrollment beginning in 2018, guaranteed availability, network adequacy, inclusion of the ECPs and actuarial value requirements. As noted in the preamble, the purpose of the Final Rule is to address the stability and competitiveness of the Exchanges as well as the individual and small group markets that have been “threatened by issuer exits and increasing rates in many geographic areas” of the country. Thus, the intention is to encourage issuers to join the market, assure a stable risk pool, incentivize individuals to maintain continuous coverage and deter adverse selection. Unless otherwise stated, the Final Rule is effective on June 19, 2017. Continue Reading