Today, the US Department of Health and Human Services issued a final rule offering a framework to help states set up Affordable Insurance Exchanges (Exchanges) that meet their residents' needs by establishing standards for health insurance plans that participate in Exchanges, determinations of an individual's eligibility to enroll in Exchange health plans and in insurance affordability programs, and employer eligibility for and participation in the Small Business Health Options Program.
The rule also provides flexibility to states in determining how they will monitor Qualified Health Plan (QHP) networks for sufficient access to services and to ensure ongoing compliance. In the rule, the Centers for Medicare and Medicaid Services (CMS) encourages states to coordinate with state departments to identify tools and strategies to monitor QHP compliance with certification standards, including standards related to network adequacy. APTA commented extensively on this provision in the proposed rule, calling the standard "too broad" and recommending that CMS adopt 4 additional requirements to "ensure that enrollees have timely and geographically accessible care as well as access to sufficiently diverse provider types from diverse health care settings." However, in the final rule, CMS states that it is "… not prescribing specific oversight and enforcement strategies" to monitor QHPs.
Additionally, essential health benefits (EHB), which are mandatory and include the category of rehabilitative/habilitative services, must be offered in QHPs. This final rule provides states guidance and flexibility in implementing EHBs in the Exchanges. A separate proposed rule will be issued this year regarding EHBs.
Today's rule combines policies from 2 Notices of Proposed Rulemaking (NPRMs) published last summer. One rule, published July 15, 2011, outlined a proposed framework to enable states to build Exchanges. A second NPRM, published August 17, 2011, outlined proposed standards for eligibility for enrollment in qualified health plans through the Exchange and insurance affordability programs, including premium tax credits.
APTA will post a summary of the rule on its Web site shortly.
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