CMS hates some agents and other draft 2017 PPACA parameters

CMS is not trying to ban balance billing, but it says patients who get out-of-network care in in-network settings, such as hospitals, should be able to count what they spend on out-of-network essential health benefits care toward their annual out-of-pocket spending maximums. (Page 230)

Standardized options plans

Some consumer groups have complained that consumers using HealthCare.gov have a hard time making true apples-to-apples comparisons because of big differences in plan cost-sharing rules. 

CMS has proposed nudging plan issuers toward more uniformity by using HealthCare.gov to highlight plans offered by issuers that voluntarily agree to base plans on a standardized benefits template. (Page 198)

The standardized option silver plan, for example, would have a $3,500 deductible, a $7,150 out-of-pocket maximum. After a patient met the deductible, the co-pay for emergency room services would be $300. An urgent care visit would not be subject to the deductible, and the co-payment would be $75. (Page 204)

Broker provisions

In provisions that apply to the exchanges that use the HHS HealthCare.gov enrollment system, CMS has proposed eliminating the requirement that the vendors responsible for training HealthCare.gov exchange agents verify those agents’ identity. (Pages 144 to 146) The exchange plan issuers already have to verify agents’ identity, so, there is no reason for the training vendors to also have to verify the agents’ identity, CMS says.

CMS would also let Web brokers handle the application process on their own systems, and connect with HealthCare.gov only for eligibility verification purposes, rather than forcing Web brokers to channel customers to HealthCare.gov for the application process.

But CMS has also included a long section on agent and broker disciplinary rules. (Pages 136 to 144) Officials have focused heavily on concerns about cases of producer fraud and abuse related to use of consumers’ personally identifiable information.

See also: NAIC fraud alert highlights consumers’ PPACA ignorance

Under a proposed regulation, “if HHS reasonably confirms the credibility of an allegation that an agent or broker engaged in fraud or abusive conduct using personally identifiable information of exchange enrollees or applicants, or in connection with an exchange enrollment or application, or is notified by a state or law enforcement authority of the state or law enforcement authority’s finding or determination of fraud or behavior that would constitute abusive conduct in such a circumstance, HHS will notify the agent or broker and terminate, immediately and permanently, the agent’s or broker’s agreements with the [exchange system] for cause,” CMS says.

“While states remain the primary oversight authority for agents and brokers, HHS reserves the right to take any other permissible enforcement or remedial action against an agent or broker for violation of federal requirements,” CMS says.

An agent or broker could appeal a termination action, CMS says.

CMS has not proposed a similar set of provisions for navigators or other types of non-agent, non-broker exchange helpers.