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Proposed ACA marketplace reforms address consumer, insurer concerns

Notice of Benefit and Payment Parameters for 2017 seeks more network adequacy controls, recalibrated risk adjustment formula

Seeking to improve the experience of consumers and health insurers alike, the federal government has proposed a host of reforms for the Affordable Care Act marketplaces.

In its Notice of Benefit and Payment Parameters for 2017, the Centers for Medicare & Medicaid Services (CMS) directly address the issue of provider network adequacy in ACA exchange plans, asking states to establish standards that are subject to minimum criteria that CMS will establish at a later date. The agency also is looking into the possibility of indicating to consumers whether an exchange plan features a broad number of providers.

The issue of narrow-network plans on the exchanges has been a controversial one, with one recent study finding that as many as 14 percent of ACA health plans lack in-network physicians in at least one common specialty. To address such concerns, state insurance commissioners have drafted a model state law to better regulate provider networks.

The CMS is also considering requiring health plans that operate on the federal exchange to count certain out-of-pocket expenses on unexpected out-of-network services toward a policy holder's annual out-of-pocket maximum, that is, if the service was performed at an in-network facility and the consumer didn't get advance notice about the out-of-network charges.

Such proposals are an "an aggressive move to strengthen regulation of the market," Caroline Pearson, senior vice president at the consulting firm Avalere Health, tells The Washington Post. Still, she worries about how some of the rules may play out for insurers, which have shown signs they are struggling in the individual market. The nation's largest insurer, UnitedHealth Group, said Thursday that it is losing money on its ACA plans and may pull out of the marketplace entirely in 2017.

Perhaps in a nod to insurers' complaints, other CMS proposals seek to make the ACA marketplace an easier place to operate, including: recalibrating the risk adjustment formula to provide greater accuracy of payments; keeping the federal marketplace user fee stable for 2017; changing the open enrollment period for 2018 and beyond to Nov. 1-Jan. 31; improving the child age rating curve to reflect risk more accurately; and streamlining direct enrollment so that customers can more easily use websites of agents and brokers in order to lessen insurers' administrative costs.

"We look forward to reviewing comments to these proposed rules to make the marketplaces work even better so that consumers will benefit from choice and competition," Healthcare.gov CEO Kevin Counihan said in a statement from CMS about the proposals.

To learn more:
- here's the Notice of Benefit and Payment Parameters for 2017 (pdf)
- read the CMS statement
- here's The Washington Post article

Related Articles:
Insurance commissioners propose more narrow-network controls
Study finds some marketplace health plans lack network doctors in key specialties
AHIP: Out-of-network bills vary greatly nationwide
UnitedHealth's exchange exit threat: What it means
Losses lead UnitedHealth to rethink role in ACA exchanges