Preparing for 2017 .......really

Nov 23, 2015

  1. Yagents
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    Yagents Guru

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    Just in case some of you actually think you'll have a job next year, mark your calendars for more of the same. Higher deductibles, 45 day OEP rush, and network crackdowns.



    Proposed Regulations on 2017 Benefit and Payment Parameters

    Cigna <[email protected]>
    Today at 2:06 PM


    November 23, 2015

    Proposed Regulations on 2017 Benefit and Payment Parameters

    On November 20, the Department of Health and Human Services (HHS) issued proposed regulations that address a wide range of Affordable Care Act (ACA) benefit provisions that will be effective for 2017 plan years. These rules are published each fall and finalized the next spring for the following plan year.

    On the same day, the Centers for Medicare & Medicaid Services (CMS) posted the draft 2017 Actuarial Value Calculator, along with the 2017 Methodology and User Guide. Links to the calculator and related documents can be found at the end of this alert.

    Here is an overview of some of the key provisions in the proposed regulations.

    2017 Out-of-Pocket Maximums

    The proposed 2017 annual out-of-pocket maximums are $7,150 for individual coverage and $14,300 for family coverage.

    2017 Marketplace Enrollment Period

    The 2017 enrollment period will follow the same timing as 2016 enrollment: November 1, 2016 through January 31, 2017.

    The proposed rules suggest changes to the automatic re-enrollment process when the plan in which an individual is currently enrolled is no longer available. Individuals who had been enrolled in a silver plan that is no longer available would be auto re-enrolled in the most similar silver plan product offered by the same insurer, rather than in a different metal level in the same product.

    2017 User Fee

    The fee insurers pay to sell individual policies through the Marketplace will remain at 3.5% of the monthly premium.

    Network Adequacy Standards

    The rules propose several changes related to network adequacy requirements for plans sold on the Marketplace.

    Treating certain out-of-network expenses as in-netw
    ork – Insurers offering plans in any Marketplace would have to provide individuals at least 10 days’ notice prior to a procedure at an in-network facility if the individual might receive out-of-network services, for example from an out-of-network anesthesiologist. If the notice is not provided, the individual would be allowed to count the out-of-network cost sharing against his or her in-network out-of-pocket maximum.
    Standards for network coverage – The rules would establish provider network adequacy standards for health plans in the federal Marketplace. These standards would cover factors such as consumer travel time and distance to providers. HHS is also considering creating standards for identifying network a strength to improve transparency for consumers.
    Coverage when provider leaves the network – The rules would impose new continuity-of-care requirements in the federal Marketplace. Insurers would have to provide 30 days’ notice before discontinuing a network provider. If an individual is receiving active treatment, the insurer would have to cover continuing care for up to 90 days or until treatment is completed.

    Standardized Plan Options in the Individual Marketplace

    To make it easier for consumers to compare costs for similar plans offered by different insurers in the federal Marketplace, certain plans will be designated as standardized plans. The current proposal includes four silver, one bronze and one gold plan. Insurers can choose to offer standardized plans, non-standardized plans or both. The standardized plans would have:

    Standard deductible amounts
    Four-tier drug formularies
    Only one in-network provider tier
    Some services, such as office visits, urgent care and generic drugs, not subject to the deductible
    A preference for copayments over coinsurance

    New Model for State/Federal Partnerships

    State Marketplaces that use HealthCare.gov’s technology for eligibility and enrollment will be known as state-based exchanges on the federal platform (SBE-FPs). States will retain primary responsibility for plan management and consumer assistance while using the federal enrollment system, including certain call center services. This model is intended to make the transition easier should additional states decide to move to HealthCare.gov in the future.

    Navigator Responsibilities

    The proposed regulations modify the requirements that apply to navigators. Navigators would be required to provide post-enrollment assistance for functions such as Marketplace eligibility appeals, application for exemptions through the Marketplace, and transitioning from coverage to care.

    Marketplace Enrollment Directly on Insurer’s Websites

    The proposed rules request comments on standards that would allow insurers and web-brokers to directly enroll individuals in the Marketplace while remaining on their own website.

    Changes to Federally-Facilitated SHOP Plans

    HHS proposes a new employee choice option on the SHOP Marketplace for small employers. Employers can currently offer their employees a single plan or the choice of plans within a metal level. Under the new “vertical choice” model, employers would be able to offer employees a choice of all plans across all available levels of coverage from a single insurer.

    Read the Fact Sheet
    Read the Proposed Regulations
    View the 2017 Draft Actuarial Value Calculator and User Guide
    Review the Calculator Methodology
    We encourage you to bookmark Cigna's health care reform website, Understanding Health Care Reform | Cigna, where we continuously update information as it becomes available.

    This document is for general informational purposes only. While we have attempted to provide current, accurate and clearly expressed information, this information is provided "as is" and Cigna makes no representations or warranties regarding its accuracy or completeness. The information provided should not be construed as legal or tax advice or as a recommendation of any kind. External users should seek professional advice from their own attorneys and tax and benefit plan advisers with respect to their individual circumstances and needs.


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    Yagents, Nov 23, 2015
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  2. Ann H
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    Ann H Guru

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    They are dreaming! How is a health plan supposed to notify you within 10 days of a procedure if one of your providers (such as an anesthesiologist) may be out of network? Unless it's a complete pre-auth, referral-only type of HMO, how would the carrier know? Crystal ball?

    I love the "standardized" benefit plan ideas. So, let's see if I've got this right. Carriers can mirror each other exactly, or not mirror each other, or both. Yeah. Uh, let's see.... We'll choose "not mirror each other" for $500 Alec.

    And lastly, what gives the administration the right to do this?

    Oh, wait. I said, "lastly" already, but I have one more. It's nice to see that the Exchanges still get their 3.5% commission... uh... errr, I mean "fee" for every plan sold in its Insurance Agency.... uh.... errr, I mean government entity.
     
    Ann H, Nov 23, 2015
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  3. dgoldenz
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    dgoldenz Moderator Moderator

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    lol @ that whole list, especially the network adequacy standards.
     
    dgoldenz, Nov 24, 2015
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  4. FLM2
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    FLM2 Guru

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    It doesn't really matter, by 2017, unless the Administration caves in and covers all potential losses, why would any insurance company want to take on this mess when they know upfront it won't be profitable?
     
    FLM2, Nov 24, 2015
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  5. kgmom219
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    kgmom219 What's Next?

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    Forget 45 days....there is NO way we are getting rates prior to election day. Plan on a 30 day OEP, folks.

    I did like the Navigator req't to offer "post enrollment support", though.
     
    kgmom219, Nov 24, 2015
    #5
  6. russelltw
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    russelltw Guru

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    Nice to see the exchange will make a higher commission than I will...
     
  7. AllenChicago
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    AllenChicago Guru

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    My thoughts exactly. Commission on Marketplace plans will be -5% across the board by then anyway.
     
  8. cadylou
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    cadylou Guru

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    I'm out - I'll be telling my on-exchange people that they need to pay close attention to how we enroll this year, since they'll be on their own next year. . . .
     
    cadylou, Nov 24, 2015
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  9. MedicareAgent
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    If people want coverage, I send them straight to my link at Healthsherpa and I do not touch a thing. I do not upload, help make first payment or anything else. Here's the link, pick what you want and watch the mailbox for further instruction.
     
  10. AllenChicago
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    AllenChicago Guru

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