from CIGNA’s Informed on Reform

Network Adequacy Standards

The final rules have adopted several changes related to network adequacy requirements for plans sold on the Marketplace.

• Transparency of network size. Beginning in 2017, Healthcare.gov plans to include a rating of each plan’s relative network size compared to other plans available in the same geographic area.
• Coverage when a provider leaves the network. New continuity-of-care requirements will apply in the Federal Marketplace. Insurers must provide 30 days’ advance notice to patients receiving treatment from a provider who is leaving the network. Insurers will have to continue in-network coverage for individuals receiving active treatment, until the treatment is complete or for 90 days, whichever occurs first.
• Treating certain out-of-network expenses as in-network. Beginning in 2018, cost-sharing amounts for certain services performed by out-of-network ancillary providers at in-network facilities must be counted toward the in-network, annual out-of-pocket maximum. Only when the insurer provides written notice to the patient—at least 48 hours prior to the time of service—may the out-of-network service be billed at an additional cost.

Comparative Effectiveness Research Fee

Also known as the Patient-Centered Outcomes Research Institute (PCORI) Fee, the Comparative Effectiveness Research Fee (CERF) will be used to conduct research to determine the effectiveness of alternative treatments.

• Insurers pay the fee for fully insured plans.
• Self-funded plans must calculate and pay their own fee.

The fee is based on the average covered lives for the applicable 12-month policy or plan year, and must be paid by July 31 each year (using IRS form 720).

• Plan year start date Feb. 1, 2014 to Oct. 1, 2014 - $2.08 fee per average covered life.
• Plan year start date Nov. 1, 2014 to Jan. 1, 2015 - $2.17 fee per average covered life.

Summary of Benefits and Coverage Template and Instructions

The ACA requires SBCs as a means to provide individuals with standard information so they can better understand and compare medical plan offerings. The final SBC template and instructions maintain material changes proposed to these documents in late February 2016. These changes include:

• Streamlined content. e.g., removal of Q&A about Coverage examples
• An additional cost example for a foot fracture treated in an emergency room
• Updated claims/pricing data for the coverage example calculator
• New minimum essential coverage and minimum value language, as well as new continuation and appeals/grievance rights language
• Revised language for some sections of the template
• An updated Uniform Glossary