Avalere Health
An Inovalon Company
Insights

May 21, 2014

HHS Releases Exchange and Insurance Market Standards for 2015 and Beyond Final Rule, Finalizing Most Provisions as Proposed

Published

May 21, 2014

On May 16, HHS released the final Exchange and Insurance Market Standards for 2015 and Beyond rule.

The rule finalizes most provisions as proposed, including policies relating to health insurance discontinuation and renewal, quality reporting and enrollee satisfaction surveys, the Small Business Health Options Program (SHOP), and adjustments to risk corridors and the medical loss ratio (MLR) requirements in light of transitional policies and technical issues associated with 2014 open enrollment. The rule also finalizes stronger standards for Navigators and other consumer assistance entities.

Consistent with the proposed rule, issuers will see some benefit from the changes to the MLR provisions and premium stabilization programs to recognize the uncertainty created by the transitional policies and technical issues of 2014. In addition, state regulators were granted slightly more flexibility to request a delay in employee choice for 2015, which should help stabilize risk pools in the small group market and encourage more issuers to participate in the SHOP. However, issuers will face greater burden from the finalized requirement for plans to provide a 24-hour expedited exceptions process for coverage of non-formulary drugs under exigent circumstances. The requirement for plans to expedite the process to cover a non-formulary drug under certain circumstances will help ensure that consumers have timely access to certain prescription drugs.

HHS intends to release technical guidance on some of these provisions, including the process by which it will make sequestered funds from the reinsurance and risk adjustment programs available to issuers in FY 2016. HHS has already released technical guidance on the proposed methodology for calculating quality ratings, which HHS intends to finalize shortly. Next year, HHS intends to release guidance on Enrollee Satisfaction Survey (ESS) vendors and details regarding the display of rating information and ESS results in marketing materials.

View HHS’ final rule.

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