Establishment of Exchanges and Qualified Health Plans

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1 Establishment of Exchanges and Qualified Health Plans I. Requirements for certification of health plans to be sold in Exchanges Exchanges must only offer Qualified Health Plans (QHPs) in Exchanges. They must ensure that QHP: Comply with Exchange processes, procedures, and requirements set forth pursuant to data collection and reporting described in subpart K of part 155 (covered benefits, rates, and cost-sharing requirements); Comply with benefit design standards, including essential health benefits (section 1302(b) of ACA), cost-sharing limits (Section 1302 of ACA), a bronze, silver, gold or platinum level of coverage (Section 1302 (d) of ACA) or is a catastrophic plan (Section 1302 (e) of ACA); Be licensed and in good standing to offer health insurance coverage in each State in which the issuer offers health insurance coverage; Implement and report on a quality improvement strategy or strategies consistent with the standards of section 1311(g) of the Affordable Care Act, disclose and report information on health care quality and outcomes described in sections 1311(c)(1)(H) and (I) of the Affordable Care Act, and implement appropriate enrollee satisfaction surveys consistent with section 1311(c)(4) of the Affordable Care Act; Pay any applicable user fees assessed under ; Comply with the standards related to the risk adjustment program under 45 CFR part 153; and Submit to the Exchange and HHS on annual basis information on drug distribution and costs. Among the other requirements discussed (this is not intended to be exhaustive): Accreditation ( )A QHP issuer must obtain its accreditation within a time period established by the Exchange under CMS states, Allowing these issuers extra time to meet the standards proposed in this section may encourage a wider variety of health insurance issuers to seek to offer QHPs through the Exchange. CMS seeks comment on the standards by which HHS should recognize accrediting bodies. Network adequacy ( ): The rule proposes discretion for Exchanges in setting network adequacy standards for participating health insurance issuers. Enrollment information ( ): CMS proposes to require that QHP issuers receive enrollment information electronically from the Exchange. CMS seeks comment on the frequency with which plans should receive electronic enrollment information. 1

2 Termination of Coverage ( ): QHP issuers must develop a policy that is uniform as permitted by the Exchange for the termination of coverage due to non-payment of premium, irrespective of Exchange standards, uniformly to all enrollees in similar circumstances. QHPs leaving Exchanges ( ): QHP issuers must continue covering benefits for each enrollee until the completion of the benefit year or plan year for the SHOP. Decertifying Plans ( ): If an Exchange decertifies a QHP, the QHP issuer must terminate coverage for the QHP s enrollees only after the Exchange has notified the those enrollees and enrollees have had the opportunity to enroll in other coverage. CMS seeks comment on the extent to which enrollees should continue to receive coverage from a decertified plan. Essential Community Providers ( ): QHP issuers include in their provider networks a sufficient number of essential community providers, where available, that serve low income, medically underserved individuals. CMS seeks comment on how to define a sufficient number of essential community providers. II. Governance and conflict of interest provisions Summary: Governance and conflict of interest guidance is spelled out in The voting members of an Exchange governing board will represent consumer interests by ensuring that membership may not consist of a majority of representatives of health insurance issuers, agents, or brokers, or any other individual licensed to sell health insurance. A State may wish to adopt more stringent or specialized conflict of interest requirements than those used in connection with regular governmental operations. Each Exchange shall publish a set of guiding governance principles that includes ethical and conflict of interest standards and disclosure of financial interests that are posted for public consumption. An Exchange must have in place procedures for disclosure of financial interest by members of the governing body or governance structure of the Exchange. SHOP exchange governance: A state may operate its individual market Exchange and SHOP under separate governance or administrative structures and if it chooses to do so, it must, where applicable, coordinate and share relevant information between the two Exchange bodies. If a state does choose to operate its individual market Exchange and SHOP under a single governance or 2

3 administrative structure, it must ensure that the Exchange has adequate resources to assist individuals and small employers. (paragraph (e) Comment is invited as to the extent to which these categories of representatives with potential conflicts of interest should be further specified and on the types of representatives who have potential conflicts of interest. III. Federally-operated Exchanges The NPRM describes the potential for states to pursue a flexible State partnership model combining State-designed and operated business functions with Federallydesigned and operated business functions. Examples of such shared business functions might include eligibility and enrollment, financial management, and health plan management systems and services. We note that States have the option to operate an exclusively State-based Exchange. HHS is exploring different partnership models that would meet the needs of States and Exchanges. (Page 19) As States, and the Federal government in connection with the Federally-facilitated Exchange, develop expertise and implement the infrastructure for Exchange operations, we anticipate sharing of information and ideas. (Page 26) There is no further detailed information about how a federally-run Exchange would operate in a state, or a timeline for implementation. IV. Changes to requirements set forth in the original timeline Conditional Approval: CMS proposes to add an option for Conditional Approval of exchanges paragraph (d) notes that although the statute requires HHS to approve State Exchanges no later than January 1, 2013, there will be systems development and contracting activities that continue to occur in 2013 after the statutory deadline for approval. In order to accommodate States that are making progress towards the operational date of January 1, 2014, HHS may issue a conditional approval. Establishment of Exchanges After 2014: CMS proposes to allow states to elect to operate an Exchange after paragraph proposes to allow States the flexibility of seeking approval to operate an Exchange even if a State is not approved to operate by January 1, A state electing to operate an Exchange after 2014 must have in effect an approved or conditionally approved Exchange Plan at least 12 months prior to the first effective date of coverage. It is assumed that first effective date of coverage will fall on January 1 of any given year because of the standardized annual open enrollment periods, so the approval or conditional approval would have to be in effect by January 1 of the prior year. 3

4 V. Navigator program Summary: The requirements for Navigators are described in To be eligible for a Navigator grant an entity must: Be capable of carrying out at least those duties described below; Demonstrate to the Exchange that the entity has existing relationships, or could readily establish relationships, with employers and employees, consumers (including uninsured and underinsured consumers), or selfemployed individuals likely to be eligible for enrollment in a QHP; Meet any licensing, certification or other standards prescribed by the State or Exchange, if applicable; and Not have a conflict of interest during the term as Navigator. The Exchange must include entities from at least two of the following categories for receipt of a Navigator grant: Community and consumer-focused nonprofit groups; Trade, industry, and professional associations; Commercial fishing industry organizations, ranching and farming organizations; Chambers of commerce; Unions; Resource partners of the Small Business Administration; Licensed agents and brokers; and Other public or private entities that meet the requirements of this section. Other entities may include but are not limited to Indian tribes, tribal organizations, urban Indian organizations, and State or local human service agencies. An entity that serves as a Navigator must carry out at least the following duties: Maintain expertise in eligibility, enrollment, and program specifications and conduct public education activities to raise awareness about the Exchange; Provide information and services in a fair, accurate and impartial manner. Such information must acknowledge other health programs; Facilitate enrollment in Qualified Health Plans; Provide referrals to any applicable office of health insurance consumer assistance or trusted state agency or organization for any enrollee with a grievance, complaint, or question regarding their health plan, coverage, or a determination under such plan or coverage; and Provide information in a manner that is culturally and linguistically appropriate to the needs of the population being served by the Exchange, including individuals with limited English proficiency, and ensure accessibility and usability of Navigator tools and functions for individuals with disabilities in accordance 4

5 with the Americans with Disabilities Act and section 504 of the Rehabilitation Act. Other key points: The Navigator must not receive any consideration directly or indirectly from any health insurance issuer in connection with the enrollment of any qualified individuals or qualified employees in a QHP. The Exchange is prohibited from supporting the Navigator program with Federal funds received by the State for the establishment of Exchanges. The federal government is considering a requirement that the Exchanges ensure that the Navigator program is operational with services available to consumers no later than the first day of the initial open enrollment period. ** CMS seeks comment on this timeframe. The Exchange must ensure that a Navigator must not be a health insurance issuer, or receive any consideration directly or indirectly from any health insurance issuer in connection with the enrollment of any qualified individuals or qualified employees in a qualified health plan. VI. State Plan Amendment Process CMS is considering the establishment of a review process for states Exchange Plans that is similar to Medicaid and CHIP for which there would be 90 days to review the plan for either approval or denial, or to request comment. If additional information is requested and received from the State, HHS would have 90 days to either approve or disapprove the plan. **Comments are sought on the appropriateness of this process and timeline. VII. Interaction with Medicaid agencies Exchanges and the Medicaid and CHIP agencies are expected to execute data use agreements that prevent the unauthorized use or disclosure of personally identifiable information and prohibit the Exchange or State agency from seeking to obtain or provide information that it will not, or does not reasonably expect to, use. CMS proposes to adopt these same requirements as data privacy and security requirements for Exchanges. 5

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