health insurance iStock_000028383644_FullThe Centers for Medicare & Medicaid Services (CMS) recently issued its proposed Notice of Benefit and Payment Parameters for 2018 (Proposed Rule) a couple of months earlier than in the past – one of the administration’s many actions aimed at setting the tone going into the election and the coming year. The release of the Proposed Rule comes as many insurers, including Aetna, Cigna, Humana, UnitedHealthcare and smaller qualified health plans (QHPs), announced plans to exit or limit participation in the Exchanges for 2017. With a targeted focus on making the Exchanges operate more efficiently, the Proposed Rule spans 293 pages of dense content with numerous proposals related to the risk adjustment program and accompanying tables and figures. Although central to insurance entities, the Proposed Rule is sure to impact patient access to healthcare services and payment to providers. To that end, CMS is asking providers to weigh in on the Proposed Rule’s policies, some of which may be more relevant than others to patients seen in the office or hospitals.

Network Adequacy

The Proposed Rule addresses network adequacy standards, in particular, by building on the minimum criteria established under 45 CFR § 156.230. In the 2017 Payment Notice, HHS finalized a policy related to “network breadth” by QHPs that will allow consumers to use Healthcare.gov to make network adequacy comparisons with those of other QHPs in the same geographic area. CMS intends to pilot a network breadth indicator in six states for plan year 2017. The results of the pilot will determine if CMS will expand it to more states in 2018.

The Proposed Rule seeks input on whether CMS should incorporate further detail into these indicators, specifically whether a plan is being offered as part of an integrated delivery system. In essence, CMS is requesting whether this information imparts a higher level of access or “may not accurately describe the ability of a consumer to access providers relative to consumers enrolled in plans that are not part of an integrated delivery system in the same county.”

For purposes of defining which plans utilize an integrated delivery system, CMS proposes to use the “alternate essential community provider standard at 45 CFR 156.235(b).” Thus, a plan would be part of an integrated delivery system if it provides a majority of covered professional services through physicians employed by the issuer or through contracted medical groups.

Surprise Medical Bills

In an effort to address escalating concerns by consumers over “surprise” medical bills that occur, for example, when care is delivered at an in-network facility by an out-of-network specialist, the Proposed Rule includes a requirement that beginning in 2018, plans count enrollee cost sharing for an essential health benefit (EHB) provided by an out-of-network provider at an in-network facility toward the enrollee’s annual deductible. CMS is soliciting comments on whether this policy should be expanded to apply to QHPs both on and off the Exchanges, regardless of whether the QHP covers out-of-network services.

Essential Community Providers

With regard to the calculation of Essential Community Providers and whether a QHP has met the minimum percentage of ECPs in a plan’s services, CMS is requesting comments on maintaining the agency’s current approach in future years and specifically requests comments on the best approach for measuring hospital participation in 2019.

Opportunity for Comment

CMS is soliciting comments on all aspects of the Proposed Rule. Comments are due on or before October 6, 2016.