Increased Consumer Protections and Transparency for 2016 ACA Plans


Prescription drug cost-sharing requirements may better inform consumer selection.

The new year brings the third year of healthcare exchanges or marketplaces and of coverage through new qualified health plans. The Commonwealth Fund’s Issue Brief, “Increased Transparency and Consumer Protections for 2016 Marketplace Plans,” addresses several key changes to qualified health plans in 2016.

The brief points out that marketplaces are trying to attract millions of additional customers this year, so changes are particularly important as new 2016 enrollees will be harder to reach because of unawareness or skepticism about the value of healthcare coverage through the ACA.

“Simplicity will be important to attract these populations and ensure that enrollment in the marketplaces continues to grow,” the authors wrote.

New this year are an out-of-pocket costs calculator, requirements about provider networks, and prescription drug cost-sharing requirements that should better inform consumer selection, the brief notes.

Also, several policy changes will help individuals with more severe health needs, including:

  • Improved prescription drug coverage for HIV/AIDS and other conditions
  • Allowing prescription drugs that are obtained through an exceptions process to count toward the out-of-pocket spending cap
  • More comprehensive and consistent habilitative coverage
  • An individual out-of-pocket spending cap within the family out-of-pocket maximum

HHS strengthened the transparency of plan networks by requiring monthly updates, more detail, and easier accessibility (such as being accessible online without the need to create an account or a policy number) of in-network provider directories. HHS will require qualified health plans to offer healthcare services that help a person keep, learn, or improve skills and functioning for daily living.

Furthermore, plans cannot impose limits on coverage of habilitative services that are less favorable than any such limits imposed on coverage of rehabilitative services. Additionally, in 2016 HHS ruled that qualified health plans must include the individual out-of-pocket maximum within the family maximum amounts, so that once a family member has spent $6850 on healthcare costs, his or her spending is eliminated.

This important change means that a person in a family with high costs will reach the out-of-pocket cap and have additional services covered regardless of other family members’ spending. The Commonwealth Fund believes this policy change will have a major effect on families where multiple members are covered under one plan, but one or 2 people have high health costs.

“Under the new rule, the high-spending (and presumably high-need) family member no longer pays cost-sharing after meeting his or her threshold, although the other members still do when they need care,” according to the report.

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