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  • OPM Final Rule Clarifies That Multi-State Plans Must Offer EHBs

    On Friday, the US Office of Personnel Management (OPM) published a final rule establishing standards for the Multi-State Plan Program (MSPP) to promote competition in the new health insurance marketplace, also known as the "exchanges," and  ensure that consumers have more high-quality, affordable insurance choices.  

    Under the MSPP, OPM will enter into contracts with private health insurance issuers to provide at least 2 Multi-State Plans (MSPs) in each state's exchange. MSPs will be established in at least 31 exchanges this year, with coverage to be extended to the exchanges/marketplaces in every state and the District of Columbia by 2017. At least 1 of these issuers must be a nonprofit entity. All state and federal laws that apply to Qualified Health Plans (QHPs) also will apply to MSPs. 

    Important to physical therapists is the rule's clarification that MSPs must offer essential health benefits (EHBs), and MSPP issuers must comply with state standards relating to substitution of state benchmark benefits or standard benefit designs. As reported in News Now on February 21, a final rule on EHBs gives states authority to impose more stringent requirements on EHBs substitution than the federal regulation, meaning that states can prohibit substitution within EHB categories altogether. Additionally, MSPP plan issuers are directed to follow state definitions of habilitative services and devices where they exist. If a state has not defined the benefits, OPM will determine them during negotiations with the MSPP issuer. To ensure network adequacy (adequate number of provider and facility types),  the rule adopts an approach in which the MSPP will establish a uniform standard for network adequacy using time and distance standards similar to the Centers for Medicare and Medicaid Services' standards for Medicare Advantage plans and Medicare Part D.

    The final rule also:

    • Reflects OPM's commitment to collaborate with states to ensure that the MSPs are competitively neutral in the marketplaces.
    • Sets standards related to how OPM will coordinate with states and HHS to approve rates, standards for rating, medical loss ratios, and an MSPP issuer's participation in reinsurance, risk adjustment, and risk corridor programs.
    • Establishes how OPM will monitor contract performance for the MSPP, including ensuring quality assurance, preventing fraud and abuse, and possible contract compliance actions.
    • Creates a process and standards for handling appeals for enrollees that are denied claims for payment or service.

    The initial open enrollment period for MSPs, as with QHPs, begins October 1 for coverage beginning January 1, 2014. Individuals and small businesses wishing to enroll in MSPs will then be able to enroll through the marketplace in their state. However, an MSP may not be available in every state until 2017.

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