2014-12-10-奥纬咨询-HHS_2016_Notice_of_Benefit_and_Payment_Parameters_18页_488kb

报告摘要

Plan Definition: A plan is defined as a combination of covered benefits, cost-sharing structure, provider network, and service area; changes to these characteristics may constitute uniform modifications.
State and Territory Rules: Territories are excluded from provisions like guaranteed availability, community rating, and single risk pool for Part 147. Guaranteed availability extends special enrollment periods with a 60-day window around triggering events; guaranteed renewability allows issuers to discontinue products without enrolling affected individuals in alternatives.
Coverage Requirements: Detailed rules on renewal, mergers, and corporate changes, with notifications required for policyholders.

Risk Adjustment Methodology: Risk adjustment fee for 2016 proposed at $1.75 per enrollee per year. Risk factors recalibrated using recent data, with minimal demographic changes; infants assigned to "Age 1" by severity. TRP contributions adjusted, with a per-member premium of $27 for 2016; reinsurance parameters include $90,000 attachment, $250,000 cap, 50% coinsurance, funding full $4 billion.
Risk Corridors and Data Collection: Risk corridors adjusted based on transitional plan enrollment; excess payments to issuers with ≥80% allowable costs. Compliance penalties noted, with default risk charges applied for non-compliance.

Definitions and Timeline: Rate increases effective for 2016 coverage; standardization of filing justification timelines. States with effective rate review programs must provide rate information publicly.
Disclosure Provisions: All rate filings requiring review must include a justification; uniform deadlines proposed for submissions, aligning with QHP application windows.

Exchange Functions: Requirement for language accessibility in at least 150 languages; non-Navigator assistance can be remote. Proposed re-enrollment hierarchies for plan changes; open enrollment extends to October–December for future years.
Eligibility and Enrollment: Special enrollment periods for various events like moves, court orders, or income changes; uniform deadlines for premium payments. SHOP adoption expands to include dependents and modified renewal services.
Quality and Certification: Enhanced plan certification for Exchanges, including readability standards. Alternate ECP standards apply in medically underserved areas.

Essential Health Benefits (EHB): Deletion of default benchmark plan references for territories. Uniform definition proposed for habilitative services; pediatric coverage through age 19. State selection of new benchmark plans for 2017.
Drug Formularies: P&T committee requirements starting 2017; expanded AHFS classification for drug coverage. Exceptions for non-formulary drugs limited to 24/72-hour determinations.
Cost Sharing and Minimum Value: Annual cost sharing limits tied to calendar years; minimum value amended to include inpatient and physician services. Contribution percentages adjusted for MEC based on premium growth.
Enforcement and Quality: Quality improvement strategies phased in, focusing on outcomes and disparities; heightened standards for reinsurance and MLR calculations.

MLR and CSR: CSR payments deducted from incurred claims; federal and state taxes not deductible in MLR. Rebates for group plans must be distributed to employees within three months.
Alignment with ACA: Overall adjustments reflect 2016 parameters, emphasizing transparency and consumer protections.

展开完整摘要