Changes Afoot for 2017 Marketplace Insurance Plans

The American Journal of Pharmacy Benefits, January/February 2016, Volume 8, Issue 1

Looking forward to the Affordable Care Act in 2017, the patient community analyzes a list of improvements that HHS has proposed for the insurance marketplace.

PRACTICAL IMPLICATIONS

In 2014, the patient community identified 5 policy areas that offered the opportunity for enhancement of the marketplace. This article highlights provisions within the Notice of Benefit and Payment Parameters that fall into these 5 categories and help ensure that patients obtain, and retain, the right coverage that meets their healthcare and budget needs in 2017.

The 5 areas are:

  • Ensure that cost-sharing structures and other plan design elements do not discriminate against people with chronic conditions and impede access to care.
  • Create transparency standards to ensure patients have access to complete details about coverage and cost of health insurance exchange plans.
  • Make insurance exchange plan materials easier for patients to understand by creating uniformity of content and design.
  • Establish continuity-of-care requirements that protect patients transitioning into new coverage.
  • Ensure that all health insurance exchange plans meet federal requirements.

Am J Pharm Benefits. 2016;8(1):34-36

The Affordable Care Act is in a perpetual state of change, though that is not necessarily a bad thing. The question facing all stakeholders in the healthcare community is whether these changes are improving the healthcare system to help patients to access appropriate care. In December 2015, HHS released a proposed rule on the Notice of Benefit and Payment Parameters (NBPP) for the 2017 insurance marketplace.1

This annual notice sets the rules of the road for insurers participating in the marketplace and creates new policies—many of which will benefit people with chronic diseases and disabilities. However, patients still await more clarity on how HHS plans to eliminate practices, such as drug tiering and other cost-sharing mechanisms, that discriminate against people with chronic conditions.

In 2014, the patient community identified 5 policy areas that offered the opportunity for enhancement of the marketplace: cost-sharing structures, transparency standards, uniformity of content and design, continuity-of-care requirements, and the need for all health exchange plans to meet federal requirements.2

This article highlights provisions within the NBPP that fall into these 5 categories and help to ensure that patients obtain, and retain, the right coverage that meets their healthcare and budget needs in 2017.

1. Ensure That Cost-Sharing Structures and Other Plan Design Elements Do Not Discriminate Against People With Chronic Conditions and Impede Access to Care

HHS may have missed an opportunity to comprehensively address discriminatory plan designs through this NBPP; however, there are provisions contained in this proposed rule that will ensure plans better meet the needs of people with chronic conditions. For example, the National Health Council (NHC) supports the approach that HHS described in this proposed rule that would set the bounds for states in developing oversight protocols for provider networks. This would require states to select an acceptable, quantifiable network adequacy metric, subject to certain minimum criteria established by HHS.

In states that do not conduct reviews, a federal default time-and-distance standard would be used. Although such standards should protect against unacceptably narrow network offerings, we believe that the individual states should first review the networks offered in their state. Federal standards and oversight should be used as a secondary protection. We encourage HHS to define state oversight of network adequacy and require strict state oversight as a first line of defense.

Adding wait times to network standards, surveying providers to determine if they are accepting new patients, and requiring issuers to be more transparent about their provider networks would improve consumer decision making, provided that HHS and the states can appropriately integrate these factors into the standards and oversight procedures.

Additionally, HHS aims to clarify which entities may administer premium and cost-sharing assistance through third parties, such as government programs, charities, and pharmaceutical companies. HHS has taken a step in the right direction by allowing cost-sharing assistance from government programs such as the Ryan White HIV/AIDS programs, whereas previous rule making only allowed premium support.

HHS also posed a question as to whether it should allow assistance from nonprofit charities. This potential change in thinking is a welcome sign to patient organizations, as many of them would like to extend their existing programs into the marketplace.

2. Create Transparency Standards to Ensure Patients Have Access to Complete Details About Coverage and Cost of Health Insurance Exchange Plans

HHS’ proposal to require qualified health plan (QHP) issuers to count cost sharing for an essential health benefit by an out-of-network provider in an in-network setting toward the enrollee’s maximum out-of-pocket limit has the potential to financially protect enrollees and would encourage greater transparency related to provider networks.

Additionally, the NBPP outlines an alternative approach of allowing plans to notify enrollees more than 10 days in advance of a potentially out-of-network service. This approach is concerning, because it would be nearly impossible for a plan to predict and would also potentially allow plans to issue general statements in standard plan materials as a means for such notification.

The proposed rule also addresses expanded duties of navigators to include specific post enrollment and other assistance activities, which may encourage an ongoing dialogue, thereby gradually improving consumer literacy and navigator services. Navigators have greatly benefited individuals, as they work to find plans that best meet the needs of patients.

Unfortunately, many of those who have enrolled through the marketplace have never previously had insurance and struggle to access the healthcare system for the first time. Expanding the role of navigators to postenrollment activities will greatly aid patients in learning how to use their insurance.

3. Make Insurance Exchange Plan Materials Easier for Patients to Understand by Creating Uniformity of Content and Design

Research has shown that without assistance, most people struggle to choose a health insurance plan that meets their needs and instead simply choose plans with the lowest premiums.2 Standardizing cost sharing across health plans is one option to simplify these choices. The NBPP proposes optional standardized plans that would have identical cost-sharing levels across the different insurance companies. The NHC has supported this concept in many of the state-based marketplaces.

However, many of the design elements in the NBPP’s proposed standard option are alarming. Although these changes represent an improvement over the status quo (eg, services available before the deductible, more co-payments than coinsurance), the proposed standard benefits are expensive compared with plan offerings currently available through the marketplace. They are also more expensive than the standardized benefits in the state-based exchanges that require standardization.

Specifically, most deductibles in the proposed standardized plans are higher than average deductibles in the marketplace, and cost sharing for drugs placed on the specialty tier is exceptionally high. This type of benefit, although designed to limit costs for healthier enrollees, would shift out-of-pocket expenses to the most vulnerable enrollees and limit the value of these plans for these individuals. Enactment of these structures may normalize high cost sharing and, thereby, limit plan access, opening the door to discriminatory practices, such as adverse tiering of drugs in standard and nonstandard plans.

4. Establish Continuity of Care Requirements That Protect Patients Transitioning Into New Coverage

Two new requirements for provider-network changes proposed by HHS will improve access to care for patients enrolled in exchange plans. HHS should finalize its proposal requiring all QHP issuers in federally facilitated exchanges to notify enrollees 30 days prior to discontinuation of a provider and, if a provider is terminated without cause, requiring QHP issuers to allow patients to continue alternative active treatment for 90 days at in-network cost.

These provisions, while simple in scope, will protect vulnerable populations in need of routine care by ensuring they flexibly transfer to new providers as their coverage shifts. The process of finding an appropriate physician can take time. These individuals should not be punished for changes that are well outside their control.

In addition, HHS should finalize its proposal to allow individuals to remain in coverage and receive a 3-month grace period if they fail to pay the January premium in full. As the exchanges continue to grow and improve, HHS should allow individuals every opportunity within reason to obtain and utilize coverage.

5. Ensure That All Health Insurance Exchange Plans Meet Federal Requirements

The proposed rule introduces a meaningful change by HHS by moving away from the department’s previously limited enforcement to a more active role in oversight. In particular, HHS has proposed new standards for decertification to address situations where a QHP issuer is the subject of a pending or existing state enforcement action (including a consent order), or where HHS has reasonably determined that an issuer lacks the funds to continue providing coverage to its consumers for the remainder of the plan year. This provision marks an important shift in federal oversight of the exchanges.

HHS should use this authority to better examine the design of plans to protect patients with complex health needs from discriminatory practices seen in the market, including adverse tiering for medications and exorbitant deductibles. HHS is uniquely suited to oversee the marketplace and state-based exchanges as it has a view into plans across all states, in addition to the fact that the Affordable Care Act squarely places the agency in this oversight role.

Refinement of the health insurance marketplace is not over by any stretch of the imagination. HHS continues to struggle with finding the right balance between all stakeholders while meeting the needs of the broad patient population in this country.

The 2017 NBPP, however, is another sign that the department is moving the marketplace in the right direction. As HHS finalizes the NBPP for 2017, it must include in its final regulations enhanced levels of patient protection contained in the proposed rule.

Author Affiliation: National Health Council, Washington, DC.

Funding Source: None.

Author Disclosures: The author reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design; drafting of the manuscript; critical revision of the manuscript for important intellectual content; and supervision.

Send correspondence to: Marc Boutin, JD, National Health Council, 1730 M St NW, Ste 500, Washington, DC 200336-4561. E-mail: mboutin@nhcouncil.org.

REFERENCES

1. HHS. Patient Protection and Affordable Care Act; HHS notice of benefit and payment parameters for 2017 [proposed rule]. Federal Register website. https://www.federalregister.gov/articles/2015/12/02/2015-29884/patient-protection-and-affordable-care-act-hhs-notice-of-benefit-and-payment-parameters-for-2017. Published December 2, 2015. Accessed January 4, 2016.

2. Measuring the patient experience in exchanges. National Health Council website. http://www.nationalhealthcouncil.org/sites/default/files/NHC-LakeResearch--Patient_Exchange_Experience.pdf. Published March 20, 2015. Accessed January 4, 2016.