On March 12, HHS published a final rule on Affordable Health Insurance Exchanges. The Exchange final rule includes standards for:
- The establishment and operation of an Exchange
- Health insurance plans that participate in an Exchange
- Determinations of an individual’s eligibility to enroll in Exchange health plans and in insurance affordability programs
- Enrollment in health plans through Exchanges
- Navigator program standards
- Employer eligibility for and participation in the Small Business Health Options Program (SHOP)
What’s noteworthy is that Exchanges can now manage the eligibility and enrollment process in the Exchange, Medicaid and CHIP. This decision will make life much easier for people who are looking to enroll in coverage of one kind or another and otherwise don’t know where to go or understand what they qualify for. The Exchange will review eligibility, manage the tax credits and subsidies, and may (depending on the state) manage the hand-off to Medicaid for final Mediciad enrollment. The other very positive decision (and a real victory for consumers) is that people can provide attestation of change in income without having to rely on tax returns, as was once suggested. Changes are also allowed below what was once a threshold of 20% decrease as there is general agreement that even a 10% decrease in income can and will make it difficult for people to afford their co-pay.
Important changes from the previous version of the rule include in §156.230, that Qualified Health Plans (QHP) must maintain a network of providers that is sufficient in the number and types of providers, including providers that specialize in mental health and substance abuse, to assure that all services will be accessible without unreasonable delay. Mental health and substance abuse providers were specifically highlighted in the rule to encourage QHP issuers to provide sufficient access to a broad range of mental health and substance abuse services, particularly in low-income and underserved communities.
Additional sections to note are:
§155.210 – Navigator program
- Directs Exchanges to develop and publicly disseminate conflict of interest standards and training standards for entities to be awarded Navigator grants.
- Applies privacy and security standards to Navigators.
- Establishes that at least one Navigator entity must be a community and consumer-focused non-profit group. This will be an attractive opportunity for many community behavioral health providers.
- Clarifies entities that are not eligible to serve as Navigators.
- Prohibits Navigators from receiving compensation by issuers for enrollment into plans outside of the Exchange.
§156.225 – Prohibits QHP issuers from employing marketing practices or benefit designs that will have the effect of discouraging the enrollment of individuals with significant health needs in QHPs.
§155.110 – Outlines that the governing board of the exchange must include at a minimum, one voting member who is a consumer representative.
The final rule on Affordable Health Exchanges can be found here: http://www.ofr.gov/OFRUpload/OFRData/2012-06125_PI.pdf, and more information on Exchanges can be found at: http://www.healthcare.gov/news/factsheets/2011/07/exchanges07112011a.html. Lastly, the regulatory impact analysis of the Exchange and Qualified Health Plans and preliminary regulator impact analysis on the standards related to reinsurance, risk corridors and risk adjustment can be found here: http://cciio.cms.gov/resources/files/Files2/03092012/cms-9989-fwp.pdf.