Reviewing the Proposed Exchange Regulations? Let State Refor(u)m Help
Two eagerly awaited health reform draft regulations are out, and stakeholders are busy reviewing them and considering the possible implications. Analyzing and preparing to comment on draft federal regulations is always a big job. But this time, State Refor(u)m is providing an online space to make this work a more collaborative and dynamic process, with the potential for richer and sharper feedback to federal regulators. We have opened a new online forum where you can digest, analyze and begin to formulate your comments on the regulations.
Instead of studying the regulations on your own, we invite everyone—state officials, experts, interest groups, consumer advocates, and other stakeholders—to submit questions, observations, analysis, and any early thoughts here. We will also post links to news articles, blog posts, press releases, draft analysis and other helpful materials.
We took a quick peek at one of the proposed regulations, Establishment of Exchanges and Qualified Health Plans, and have identified six key areas that are important to states and where the preamble notes that CMS is particularly interested in receiving comments.
- Exchange Governance Conflict of Interest: The proposed regulation prohibits Exchange governing boards from having a majority of representatives with a conflict of interest. It enumerates broad categories of board members that have an inherent conflict of interest: insurance issuers, agents or brokers or any individual licensed to sell insurance.
Where CMS wants input: Are there ideas about other categories of board members with potential conflicts of interest? Should CMS be more specific about conflict of interest?
- Consumer Assistance: The proposed regulation provides guidelines for the Exchange website, call center and Navigator program. The call center must be toll-free and address the needs of consumers requesting assistance. The website must include comprehensive information on plans, including information about cost, quality, customer satisfaction and transparency of coverage measures. It also lists entities eligible to serve as Navigators, and prohibits Navigators from receiving compensation from insurance companies for enrollment in Qualified Health Plans (QHPs) during their term as Navigators.
Where CMS wants input: Should CMS propose additional requirements on Exchanges to make determinations regarding Navigator’s conflicts of interests? Should CMS require that at least one of two types of Navigator entities be a community and consumer-focused nonprofit; or require Navigator grantees to reflect a cross-section of stakeholders?
- Enrollment: The proposed regulation lays out many details for enrolling individuals in Qualified Health Plans (QHPs) and terminating their coverage. It says that Exchanges must accept plan selections, notify issuers, and transmit information necessary for enrollment. It also requires the Exchange to use a single application, or an alternative application as approved by HHS, to determine eligibility for QHPs, advance payments of premium tax credits, cost-sharing reductions, Medicaid, CHIP or Basic Health Program where applicable. It sets out that Exchanges must provide an initial open enrollment period that begins October 1, 2013 and extends through February 28, 2014 and provides the dates of coverage that correspond to enrollment. It also requires the Exchange to provide special enrollment periods in the case of nine different triggering events.
Where CMS wants input: What is the general feedback about the duration and calendar dates of the initial open enrollment period? What is the reaction to the requirement that an individual should be able to file an application in person? Should CMS allow twice-monthly effective dates of coverage? What time of notification of open enrollment periods should CMS require? What ideas are out there on how to make automatic enrollment and termination work when an individual’s specific QHP is no longer offered, and the issuer offers other QHPs, but the individual has not made a new enrollment decision?
- State Exchange Plan: The proposed regulation requires states that choose to establish an Exchange to have an Exchange plan, similar to a Medicaid plan, that will be approved by HHS by January 1, 2013. States would then be required to report significant changes to the plan in writing to HHS and receive approval. In states where the federal government has started to run the Exchange, a state may begin to operate an Exchange after 2014. But such a state must have an approved Exchange Plan at least 12 months prior to the Exchange’s first effective date of coverage, as well as a joint state-HHS plan to transition from the federal Exchange to a state-based Exchange at a later date.
Where CMS wants input: What is the reaction to modeling the Exchange process on the existing process for Medicaid and CHIP plans and plan amendments?
- Health Plan Certification: The proposed regulation requires Exchanges to have processes in place for certification, recertification and decertification of QHPs. It also requires Exchanges to establish a timeline for accreditation, network adequacy standards, and a process to establish service areas. The preamble lays out many different ways states can approach plan certification from “any willing plan” to an active purchaser model.
Where CMS wants input: What is the best way to coordinate the requirement for plans to justify premium increases in the Exchange (as part of certification) with the state rate review process?
- SHOP Exchanges: The proposed regulation allows states that choose to run an Exchange to operate the individual market Exchange and Small Business Health Options Program (SHOP) under a single or separate administrative and governance structure. A SHOP is required to carry out some, but not all the functions of an individual market Exchange. A SHOP is required to carry out certain unique functions, including facilitating certain special enrollment periods, allowing employer choice, and aggregating premiums. It is also required to facilitate enrollment by receiving information electronically; establishing protocols to ensure integrity of financial transactions; providing new enrollees with enrollment information; providing summary of benefits and coverage to employers; keeping files up to date monthl; and communicating with enrollees about receipt of enrollment information.
Where CMS wants input: What is the reaction to the special enrollment periods for the SHOP and how they might differ from those for the individual market in the Exchange?
What are you doing to unpack and analyze the proposed Exchange regulations? We invite everyone—state officials, experts, interest groups, consumer advocates, and other stakeholders—to submit questions, observations, analysis, and any early thoughts you are discussing around your water cooler here.
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