August 15th, 2012 - Health Affairs
On August 14, 2012, the Department of Health and Human Services took one step
closer to implementation of the Affordable Care Act health insurance exchanges
by releasing the final version of its Blueprint for Approval of Affordable State-based and State
Partnership Insurance Exchanges. This document includes the declaration
letter and application form which must be submitted by a state that elects to
operate a state-based or partnership exchange. The document was released
in conjunction with the first of four regional implementation fora that HHS is
holding in Washington, Atlanta, Chicago, and Denver in August to discuss
exchange implementation with states and stakeholders.
The final Blueprint is very similar to the Draft Blueprint released by HHS in May, which I described in an earlier post. The Blueprint describes
the respective functions of the state and federal government in a full
state-based, state partnership, and federally facilitated exchange. Even
in a full state-based exchange, the state can cede certain functions to the
federal government, such as responsibility for determining eligibility for
exemptions and for premium tax credits and cost-sharing reduction payments, and
for operating the risk adjustment and reinsurance programs. Conversely,
even in a full federally facilitated exchange, states can operate the
reinsurance program and make Medicaid determinations.
The application part of the Blueprint is essentially a checklist of the
activities and characteristics of an exchange, including legal authority and
governance; consumer and stakeholder engagement and support; eligibility and
enrollment; plan management; risk adjustment and reinsurance; the SHOP (small
business) exchange; organization and human resources; finance and accounting;
technology; privacy and security; oversight, monitoring, and reporting; and
contracting, outsourcing, and agreements.
Whatfs New In The Final Blueprint?
There are only a few changes between the Draft and Final Blueprints.
The most significant is probably the recognition of a new category of gin-person
assistance programs,h distinct from the navigator programs. The ACA
prohibits the payment of navigators out of state establishment grant
funds. But consumer assistance will be necessary prior to time the
exchanges become self-supporting from user fees in 2014. The consumer
assistors can be funded from establishment grants and will help bridge the gap
during the initial open enrolment period in 2013. They may continue to
play a role after that time.
There are also new provisions in the Blueprint recognizing the regulatory
role of the states with respect to navigators in the federally facilitated
exchanges. The navigator program was a major topic of discussion at the
National Association of Insurance Commissioners summer meeting in Atlanta,
August 9 to 14. Brokers and agents appear to see navigators as competitors
and want to see individual navigators regulated much like agents.
Consumer advocates envision a program like the Medicare State Health
Insurance Assistance (SHIP) program, in which organizations will receive
navigator grants and carry out consumer assistance activities through employees
or volunteers, with accountability resting primarily at the organizational
level. Navigators will assist consumers, like agents and brokers, but will
be different from agents in that they will not sell insurance The
Blueprint calls for oversight to ensure that navigators are properly trained,
avoid conflicts of interest, and protect the privacy and security of consumers.
These are requirements on which everyone can agree.
The Final Blueprint also gives greater attention than did the Draft to
regulation of web-based brokers. Although web-based brokers can play an
important role in bringing enrollees to the exchange, consumer advocates have
expressed concern about the role web-based plan chooser tools can play in
shaping consumer decisions. The Blueprint calls for close oversight of
web-based brokers.
Finally, the Final Blueprint drops the requirement found in the Draft
Blueprint that states have a plan for transitioning enrollees from state high
risk pools, recognizing that the ACA does not require that state high risk pools
end when the exchanges begin (unlike the federal Preexisting Condition High Risk
Pool, which does end).
National Association Of Insurance Commissioners (NAIC)
Developments
The NAIC Health and Managed Care Committee approved five
exchange white papers at its summer meeting, covering network adequacy, form
review, rate review, accreditation and quality, and marketing and consumer
information. These should be very helpful to states pursuing
exchanges. On August 8, immediately preceding the NAIC summer meeting, the
NAIC System for Electronic Rate and Form Filing (SERFF) held a full day
informational session to describe the progress it is making in creating a system
for health insurers to file information that exchanges will need on qualified
health plans. At its summer meeting, the NAIC also created a new subgroup
to discuss issues affecting states that choose not to establish exchanges.
Finally the NAIC consumer representatives released a comprehensive guide for state and federal regulators for
implementing ACA insurance reforms.
Catching Up On Implementation News
On July 20, 2012, HHS released a final rule on data collection to support standards related to
essential health benefits and recognition of entities for accreditation of
qualified health plans. The final rule came only a month and a half after
HHS had published a proposed rule, warp speed for federal rulemaking, but
the September 30 deadline for states to identify EHB plans is fast approaching,
and states need the data to identify EHB plans.
The data collection rule addresses data that must be submitted to HHS by the
issuers of the three largest small group products in each state regarding its
highest-enrollment health plan. gHealth planh is defined under the rule to
include riders that are part of the plan. Data that will be collected
includes quantitative limits on coverage.
Under the proposed rule, data was also to be collected on non-quantitative
limits, such as step therapy or prior authorization. Under the final rule
this requirement was dropped. This presumably means that non-quantitative
limits will not be part of the EHB, but it is unclear whether such limits will
be relevant in some way to determining EHB compliance. The actual data
that must be collected is listed here.
The final rule on accreditation preserves the two-phase approach to
certifying accreditors proposed earlier. It explicitly recognizes the NCQA
and URAC as accreditors for the first phase (for 2014 and 2015), contingent on
their providing specific information within 60 days demonstrating that they meet
ACA requirements. The final rule retains the requirement of accreditation
at the product-type level (rather than at the issuer level on the one hand, or
metal-tier level on the other), but exceptions can be granted when a particular
product has too small an enrollment to allow a methodologically-sound analysis
of the product. Accreditors must submit to the exchange-specific data on
accredited plans, but may not submit personally identifiable data.
For phase one accreditation, the rule identifies fairly minimal requirements,
but in response to comments the preamble suggests that additional requirements
will be considered for phase two (for 2016 and following).