Some Changes in Store for 2016 Health Plans that Affect Consumers

Although open enrollment for the 2015 coverage year recently ended, insurers and marketplaces alike are already gearing up for 2016.  As part of their preparation, they will be using the guidance outlined under the 2016 Letter to Issuers and the 2016 Benefit and Payment Parameters Final Rule. Both documents make some changes to 2016 health plans and what will be available to marketplace consumers through the federally facilitated marketplaces. Below we summarize some changes that consumers can expect in 2016.

Access to Formulary and Provider Directory

With the 2016 plan year, consumers should be able to easily access a health plan’s formulary and provider directory on an insurer’s website without creating an account or entering a policy number to access the information.

Formularies must be up-to-date and accurately list all covered drugs including information on any restrictions on obtaining covered drugs (e.g., requiring prior authorization) and any tiering structures under the formulary. If multiple formularies exist, an issuer must clearly identify information so that a consumer can easily discern which formulary applies to which health plan. If a health plan makes any mid-year changes to the formulary, it must update its formulary prior to making those changes. Health plans must also ensure that the website link to its formulary is the same formulary link as the one provided in the Summary of Benefits and Coverage and the Marketplace website.

Provider directories must be accurate and show which providers are accepting new patients, provider location, contact information, specialty, medical group and any institutional affiliations. If there are multiple provider networks and plans, an insurer must clearly identify information so that a consumer can easily discern which provider participates in which plan, including any tiered networks. Provider directories must be updated at least once a month.

While not required, CMS encourages insurers to “honor” what is listed in their provider directories when information is inaccurate. However, it’s unclear whether this suggested means that the insurer must give consumers an option to change plans if they select a plan based on an inaccurate provider directory, or simply that the plan must hold the consumer harmless from any out-of-network cost-sharing if they receive services from a provider inaccurately listed in the provider network.

Information about Marketplace Quality and Coverage

Starting in 2016, information about the quality of marketplace coverage and insurer practices will be available to the public, although the Department of Health and Human Services (HHS) has yet to provide specifics. Under the Affordable Care Act (ACA), HHS must develop quality data collection and reporting tools: a Quality Rating System (QRS), a Quality Improvement Strategy (QIS) and an enrollee satisfaction survey designed to assist consumer selection of a marketplace plan. According to HHS, it will begin to phase in specific quality reporting in 2016.

Similarly, the ACA requires insurers to report to the marketplaces, states, and HHS information on how they are providing coverage. The types of information required include claims payment policies and practices, enrollees’ use of out-of-network services, and the number of denied claims. Although required in 2016, HHS intends to solicit additional comments prior to finalizing a specific approach on how it will collect and display this information in 2016.

Access to Prescription Drugs Not on a Formulary

Starting in 2016, all health plans must provide a standard exception process for prescription drugs, which allows an enrollee to request and gain access to a clinically appropriate drug that’s not on a plan’s formulary. This is similar to an already-existing requirement that they provide an expedited exceptions process for enrollees to obtain non-covered drugs during exigent circumstances; for example, when an enrollee has a serious health condition that can jeopardize the enrollee’s health or when an enrollee is undergoing a course of treatment using a non-formulary drug.  Under the expedited exceptions process, a health plan must make a coverage decision within 24 hours of a request.

Under the standard exception process, enrollees can request coverage for a non-formulary drug that is clinically appropriate, but not needed on an exigent basis. Following a request for coverage, the health plan must make its coverage decision within 72 hours. If a health plan approves the request for the non-formulary drug, it must provide coverage for the duration of the prescription including all refills and count any cost-sharing towards the plan’s annual maximum out-of-pocket costs.

In addition, health plans must make available an external review by an independent review organization for any denied requests either through the standard or expedited exceptions process. The external review must also apply the same timeframes for a decision related to the internal review (i.e., 24 hours under an expedited exception process and 72 hours under a standard exception process).

HHS also continues to encourage insurers to provide transitional coverage of non-formulary drugs for new enrollees and their first 30 days of coverage, although it is not making this transitional coverage policy a requirement.

Habilitative Services

In 2016, health plans must use the following federal definition of habilitative services in states where the term is undefined or is not as or more protective of consumers: health care services that help a person keep, learn, or improve skills and functioning for daily living; these services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. Insurers will no longer be able to define habilitative services absent a state definition.

HHS’ required changes have two primary purposes. First, they should improve consumers’ ability to make informed plan-to-plan comparisons. Second, they could help improve the value of coverage, particularly for those who need access to prescription drugs and habilitative services. While they are relatively modest changes, they signal that HHS is monitoring consumers’ experiences shopping for and using coverage and making adjustments to address known problems or gaps.

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The opinions expressed here are solely those of the individual blog post authors and do not represent the views of Georgetown University, the Center on Health Insurance Reforms, any organization that the author is affiliated with, or the opinions of any other author who publishes on this blog.