CMS urges tighter standards for 2015 Obamacare plans

Officials proposed greater regulation on health plans sold through public exchanges next year, following consumer complaints.

Life & Health


Prompted by complaints from health insurance consumers, officials at the Center for Medicare and Medicaid Services (CMS) unleashed more than 270 pages of new rules and guidelines for insurers participating in state and federal exchanges in 2015.

 The new rules seek to scrutinize health plans more closely, ensuring consumers greater access to local providers, prescription drugs and primary care office visits.

If the proposed rules are adopted, insurers will be required to hold contracts with at least 30% of essential community providers in their service area, including community health centers, HIV/AIDS clinics, family planning clinics and children’s hospitals. In order to assure this is the case, CMS plans to establish its own process for certifying adequate provider networks, cutting out the role of state regulators.

“If CMS determines that an issuer’s network is inadequate under the reasonable access review standard, CMS will notify the issuer of the identified problem area(s) and will consider the issuer’s response in assessing whether the issuer has met the regulator requirement and prior to making the certification or recertification determination,” the document reads.

Under the proposed rules, carriers must also provide direct links to prices for each prescription drug and pay for a 30-day supply of any new drug that a new customer had been taking—even if the drug would not have ordinarily been covered.

Stephen Hurd, an insurance agency owner in San Diego, is shocked at the proposed changes. While he acknowledges that his clients have encountered difficulty finding providers, he attributes this to the provider community itself—not insurers.

“The plans are fine. The problem is that doctors aren’t accepting them because of their fee schedules,” Hurd said. “Doctors are opting out at an alarming rate.”

He also believes CMS is “absolutely right” to worry about consumer access to prescription drugs through exchange plans. And while the decision not to cover payment for certain drugs lies with carriers, he believes the choice was necessary to keep premiums affordable.

Changing standards now could be dangerous for participating insurers, and costly to clients.

“I was really optimistic [on healthcare reform] in the beginning because it brought in all these people who were estranged from the system, but if they want to tighten plan standards now, I think they’re in la-la land,” Hurd said. “It’s a train wreck waiting to happen from what I can see. I don’t know how people are going to be able to absorb these costs.”

America’s Health Insurance Plans (AHIP) has already expressed its disapproval in comments filed on the proposed changes. Dan Durham, executive vice president of policy and regulatory affairs for AHIP, said CMS’s proposals would make coverage unaffordable for many Americans—including the crucial younger demographic.

“Policies that increase the cost of coverage or restrict consumer choice may encourage individuals to forego purchasing coverage until they are sick or injured,” Durham wrote. “This is particularly true for young and healthy individuals…We remain concerned that adverse selection and unnecessarily high costs will occur in the absence of broad market participation.”

AHIP also expressed concerns that CMS was planning so many new requirements just weeks before insurers must present their applications for 2015. Deadlines in some states begin in April.

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