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HHS Finalizes 2017 Guidance for Qualified Health Plan Issuers

The U.S. Department of Health and Human Services (HHS) has finalized a letter that provides operational and technical guidance to issuers of qualified health plans (QHPs) through the federally facilitated health insurance marketplace (FFM) for calendar year 2017.

The letter, from the HHS Center for Consumer Information and Insurance Oversight (CCIIO), finalizes essential community provider (ECP) standards that are unchanged from 2016:

  • Each QHP network must include at least 30 percent of all available ECPs in a service area.
  • Each QHP must offer contracts to at least one ECP in each ECP category in each county of a service area and to all available Indian Health Services/tribal health care providers in a service area.

Contracts must offer terms comparable to those for a similarly situated, non-ECP provider. A QHP that cannot achieve 30 percent participation still may be certified if it provides a satisfactory narrative justification describing how the plan’s provider networks offer an adequate level of service for low-income and medically underserved enrollees; and how it plans to increase ECP participation.

CMS Finalizes Payment Parameters, Standards Rule

The Centers for Medicare & Medicaid Services (CMS) also finalized its rule outlining payment parameters and standards for insurance plans, including QHPs, offered in health insurance marketplaces.

The rule did not finalize a proposal to have CMS establish a process through which states would be responsible for selecting minimum network adequacy standards and reviewing QHPs in FFMs. However, CMS did finalize other enrollee protections, such as requiring issuers in FFMs to provide 30-day written notice to enrollees of disruptions in the QHP network. The agency also finalized its intentions to develop ratings of each QHP’s network coverage that will be available to the public through HealthCare.gov.

Additionally, CMS finalized proposed patient safety requirements that hospitals with more than 50 beds must meet to be able to contract with a QHP beginning in the 2017 plan year. Specifically, the hospital must use a patient safety evaluation system through a patient safety organization and implement a “comprehensive person-centered hospital discharge program to improve care coordination and health care quality for each patient.”

Contact Director of Policy Erin O’Malley at at eomalley@essentialhospitals.org or 202.585.0127 with questions.

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About the Author

Gontscharow is a senior policy analyst for America's Essential Hospitals.

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