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  • New CMS Rules Target Consumers, Quality Reporting

    The US Centers for Medicare and Medicaid Services (CMS) has released a final rule (.pdf) on Exchange and Insurance Market Standards for 2015 and beyond that the agency claims is "aimed at giving consumers additional tools to evaluate their options and find plans that best meet their needs and budget." A summary of the rule is also available for download.

    The rule covers a range of issues including consumer notices, state restrictions on navigators, the Small Business Health Options Program (SHOP), and cost sharing. The changes, which will be implemented beginning in 2015, address the following areas:

    • The final regulation clarifies situations under which state restrictions of consumer assistance personnel (navigators, assisters, and certified application counselors) are preempted by federal law. It also imposes new federal restrictions on the consumer assistance personnel and authorizes civil money penalties on those who violate their federal obligations, breach the confidentiality of patient information, or assist in enrollment fraud. The final rule recognizes that states may regulate these personnel as long as the state regulations do not conflict with federal law or prevent the personnel from carrying out their responsibilities.
    • The new rule requires issuers to use standardized notices when renewing coverage or discontinuing products. The rule also addresses when insurance plans can modify coverage and when that modification constitutes termination of coverage.
    • For 2015, the maximum annual limit on cost sharing will be $6,600 for individual coverage and $13,200 for family coverage.
    • CMS reaffirms in the final rule its commitment to permit employee choice in the federal SHOP exchange beginning in 2015.
    • SHOP exchange rules will be modified to provide for an annual open enrollment period for all SHOPs aligned with the open enrollment period for the individual market.
    • The final rule provides additional guidance on the exchange quality reporting system. A number of state exchanges already report quality information on qualified health plans (QHPs), and the federal exchange intends to begin doing so in 2016 for the 2017 coverage year.
    • The US Department of Health and Human Services will be allowed to consult and share information concerning QHP insurers with other state and federal regulatory and enforcement agencies as necessary. The rule requires HHS to give insurers a 30-day notice setting out alleged violations and giving an opportunity to respond before the imposition of civil money penalties.

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