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Proposed Rule from HHS Changes Standards for ACA Individual and Small Group Marketplaces 

by Neil B. Krugman

Published: February, 2017

Submission: March, 2017


In one of the first concrete developments related to the Affordable Care Act (ACA) changes following Dr Thomas E Price’s approval as Secretary of the Department of Health and Human Services (HHS), a Notice of Proposed Rule making was recently released by HHS. The recent release by HHS stated a goal of helping to stabilize the individual and small group marketplaces established by the ACA. The proposed rule would amend standards relating to special enrollment periods, guaranteed availability, and the timing of the annual open enrollment period in the individual market for the 2018 plan year. The proposed rule would also modify standards related to network adequacy and essential community providers for qualified health plans (QHPs) (i.e., plans that are certified as meeting the ACA’s requirements and are allowed to participate in the marketplaces); and the rules around actuarial value requirements. 

One of the proposed changes that will be of most interest to providers is to place greater reliance on the states, versus HHS, in developing and enforcing network adequacy standards, provided that a state has a sufficient network adequacy review process.  In states that do not have the authority and means to conduct sufficient network adequacy reviews, HHS would apply a standard similar to the one used in the 2014 plan year and would rely on an issuer’s accreditation (commercial or Medicaid) from an HHS-recognized accrediting entity (e.g., the National Committee for Quality Assurance, URAC,  and the Accreditation Association for Ambulatory Health Care).  Unaccredited issuers and standalone dental plans would be required to submit an access plan to HHS that demonstrates they have standards and procedures in place to maintain an adequate network consistent with the National Association of Insurance Commissioners’ Health Benefit Plan Network Access and Adequacy Model Act.
Other notable changes for providers in the proposed rule are modifications to the standards for the inclusion of  essential community providers (ECPs) in healthplan networks.  (ECPs are safety-net hospitals, community health centers, family planning clinics and other similar providers that predominantly serve low-income and medically underserved individuals.) These changes would allow issuers to use a write-in process to identify ECPs that are not on the HHS list of available ECPs, and lower the ECP standard to 20 percent (rather than 30 percent).

Many of the other proposed changes, such as the amendments to the standards relating to special enrollment periods, guaranteed availability, and the timing of the annual open enrollment period, would affect issuers and enrollees more directly than providers



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