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Feb 06, 2014

Draft 2015 Letter to Issuers in the Federally-facilitated Marketplace (FFM) Institutes New Requirements and Standards

Published

Feb 06, 2014

On Feb. 4, CMS published a draft letter to issuers seeking to offer qualified health plans (QHPs) and standalone dental plans (SADPs) in the FFM or federally-facilitated small business health options program (FF-SHOP).

The letter offers plans operational and technical guidance for participation in the FFM. CMS also proposes to institute more comprehensive reviews of rates, networks and discriminatory benefit designs. For example, CMS is increasing the essential community provider (ECP) standards and will no longer utilize issuer accreditation as part of its evaluation of network adequacy.

In future rulemaking, CMS also intends to propose that marketplaces may require plans to temporarily cover non-formulary drugs to new enrollees.  This would include drugs that are on the issuer’s formulary but require utilization management (UM), as if they were on the issuer’s formulary, during the first 30 days of coverage to reduce disruptions in care beginning Jan. 1, 2015. CMS also reiterated that all QHPs provide an up-to-date formulary link that includes tiering and cost-sharing. Finally, to improve clarity with respect to drug coverage and payment, plans can indicate whether they consider a drug a medical benefit when submitting their drug lists to CMS, complying with essential health benefits standards.

Comments on the draft letter are due Feb. 25. In their letter, CMS outlines several proposals which they will release in future regulatory guidance, including coverage of non-formulary drugs and coverage of the initial three primary physician visits. Based on the timeline outlined in the letter, issuers will submit their 2015 plan designs to the FFM between May 26 and June 27.

To read CMS’ draft letter, click here.

For select rule highlights, see below:

  • CMS no longer plans to utilize issuer accreditation as part of its evaluation of network adequacy. Instead for 2015, issuers are required to submit a provider list that includes all-network providers and facilities in the plan’s network.
  • CMS proposes to increase the essential community providers (ECP) standard and require QHP issuers to include at least 30% of all ECPs in their service area as part of their provider network. If a plan covers less than the required 30%, it must submit a justification to CMS describing how its network provides adequate service for low income/underserved enrollees.
  • While CMS does not intend to duplicate state rate reviews, it will conduct outlier tests on QHP rates to identify rates that are relatively high or low compared to other QHP rates in the same rating area.
  • CMS to consider requiring plans, or at least one plan at each metal level per issuer, to cover three primary care office visits prior to meeting any deductible.
  • CMS intends to review plans that are outliers based on an unusually large number of drugs subject to prior authorization and/or step therapy within a particular category and class.
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