Politics & Government

HHS proposes new rule changes for 2016 marketplace coverage

The Obama administration proposed significant rule changes late Friday for state and federal marketplaces and their participating insurers beginning in the 2016 benefit year.

The new proposals, posted in a “fact sheet” on the Centers for Medicare and Medicaid Services website, are designed “to improve consumers’ experience and ensure coverage is affordable and accessible” in the individual and small group markets.

One proposal would require premium increases of 10 percent or more - and those that exceed a specific state threshold - to be publicly disclosed and explained. State regulators or HHS would also have to determine if the rate hike requests are unreasonable.

Rate reviews are currently handled at the “product,” or group level, which could include many different plans in various metal tiers. The new proposal would trigger a review when any plan within such a group “exceeds the applicable threshold,” HHS wrote.

Another proposal calls for states with rate review authority to display information on the rate hike requests on their websites.

HHS also wants the open enrollment period for individual health plans to run from October 1 through December 15 for the upcoming benefit year.

The agency is also calling for pediatric benefits to be provided until the end of the plan year that the enrollee turns 19-years-old.

New guidelines also call for more detailed procedures for determining whether a plan member can get access to a drug that’s not covered by their plan. If the plan denies coverage, HHS wants to require an external review of the decision.

HHS also wants insurers to provide most drugs at network retail pharmacies, not just through mail order pharmacies.

Enrollees who don’t take action to enroll are now re-enrolled in their current plan, even if the premiums have increased. HHS is considering options to re-enroll these plan members in a lower-cost plan.

To read all of the proposals, go to http://go.cms.gov/11M2yY2