The rule describes payment parameters applicable to the 2015 benefit year and standards relating to the premium stabilization programs, the open enrollment period for the 2015 plan year, the annual limitations on cost sharing, consumer protections, financial oversight and the Small Business Health Options Program (SHOP). While CMS changed a few items from its proposed rule, many provisions remain the same.
The commercial health plan market will be affected by most, if not all, provisions of this final rule. Lowering the reinsurance attachment point will help issuers stabilize premiums, especially during the early years of the ACA. Also, CMS lessened the proposed standards for plans to demonstrate that their qualified health plans (QHPs) in the Federally-facilitated Marketplace are “meaningfully different.” However, the extension of the 2015 open enrollment period heightens concerns about risk selection and raises questions about continuation of coverage and/or retroactive enrollments for individuals who do not enroll until Feb. 2015. In addition, the extension of the state exchange Blueprint deadline may influence whether issuers choose to sell products in certain states if the later deadline results in states imposing new requirements in the QHP filing process.
Compared to the proposed rule, the final rule lowers the maximum out-of-pocket (MOOP) limit on cost-sharing and the deductible limit for individuals and families. Therefore, consumers will likely have more access to services, including prescription drugs.
CMS is scheduled to publish the final rule in the Federal Register on March 11.
View CMS’ final rule.
View the 2015 actuarial value calculator.
Below, find selected highlights from the rule:
- Reinsurance: CMS will lower the 2014 attachment point for the reinsurance program from $60,000 to $45,000. For 2015, CMS finalized its proposal for a reinsurance attachment point of $70,000, a reinsurance cap of $250,000, and a coinsurance rate of 50 percent. Self-insured, self-administered group health plans are exempted from reinsurance contributions for 2015 and 2016.
- Risk corridors: To align with the transitional policy extension, CMS will vary the state-specific percentage adjustment to the risk corridors formula based on the percentage enrollment in transitional plans within in a state.
- 2015 Open Enrollment: The open enrollment period for plan year 2015 will run from Nov. 15, 2014, through Feb. 15, 2015.
- Out-of-Pocket Maximums and Deductibles: Compared to the proposed rule, the MOOP limit on cost-sharing for individuals and families will be lower.