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What the PPACA exchange cops hope to bag

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The managers of the federal health insurance supermarket seem to have decided to try to be polite to the insurers that brave uncertainty to put plans on its shelves.

The Centers for Medicare & Medicaid Services (CMS) has come out with a list of 2015 exchange plan compliance review priorities that’s almost the same as the list of priorities CMS issued for 2014.

The compliance priority list shows what CMS officials will look for when review the insurers issuing qualified health plans (QHP) through the public exchanges that CMS runs for the U.S. Department of Health and Human Services (HHS).

Officials emphasize that the list does not put any limits on the authority of CMS to decide what to review.

“The compliance review that is the subject of this document is separate from other audits and reviews that may be conducted to assure compliance” with PPACA, officials say.

Officials say QHP issuers could also face the following types of compliance efforts:

  • PPACA minimum medical loss ratio (MLR) compliance audits.

  • Policy and rate filing reviews.

  • Audits of plans eligible for PPACA reinsurance program payments.

But CMS officials have a reason to be as welcoming to health insurers as they can be, under the circumstances: CMS is waiting to see what QHPs insurers want to offer through the system in 2016. Applications for 2016 slots are due May 15.

Dental plan issuers expressed strong interest in selling stand-alone dental plans (SADPs) through through a voluntary notice program, but HHS collected the SADP notices before oral arguments in the King vs. Burwell U.S. Supreme Court case drew attention to the possibility that HHS may lose the ability to offer PPACA premium subsidies in the state that use the enrollment system.

For a look at how some of the returning compliance priorities look the second time around, and at a new set of compliance priorities, read on.


1. Enrollment and termination management

In 2015, a QHP issuer is supposed to adhere to some requirements that were already in effect in 2014 but, at that point, may not have been realistic.

A QHP issuer is supposed to allow for enrollment through the exchange, not just through direct enrollment.

A QHP issuer is also supposed to reconcile enrollment files with the exchange at least once a month, send coverage termination notices to affected enrollees promptly, and maintain coverage termination notices in accord with exchange standards.

It’s not clear from public HHS documents how well QHP issuers could have met those standards in 2014, or can use automated HHS exchange systems to meet those standards this year.

See also: Open questions slow PPACA exchange revamp

Supreme Court courtroom

2. QHP management

The participating insurers are supposed to make sure the QHPs they offer through the exchanges meet many rating and certification criteria.

The insurers must make sure that the rates are the same whether a QHP is sold through an exchange, directly through the issuer, or through an agent.

The insurers must make sure the documents are accessible for people with disabilities and for people with limited English proficiency.

Finally, insurers that are terminating QHPs must meet exchange notification and reporting standards, and make sure they are meeting benefits coverage obligations to the enrollees.

A year ago, no insurer had ever had a chance to terminate a QHP. This year, some insurers have had reasons to withdraw QHPs, or avoid active efforts to attract new enrollees, and at least one insurer has shut down entirely.


3. Covered drug lists

The biggest change in the 2015 QHP compliance review priority list is a section on prescription drug formularies, or lists of drugs that a plan covers.

This year, CMS notes in the priority list that, to provide the minimum required “essential health benefits” (EHB) package, a QHP must cover “at least the greater of one drug in every United States Pharmacopeia category and class or the same number of prescription drugs in each category and class of [the] EHB benchmark plan.”

A QHP also must have procedures an enrollee can use to get access to a clinically appropriate drug not covered by the health plan, CMS says.

Over the past year, some patient advocacy groups and others have accused insurers of pushing the sickest patients toward other insurers by offering formularies with options for people with conditions such as HIV.

See also: Drugmakers turn up heat on insurers