February 25, 2015

CMS Issues Rule on Several ACA Components

On Friday, the Center for Medicare and Medicaid Services (CMS) issued a 476-page final rule on a variety of ACA topics, effective beginning in plan year 2016. See this CMS press release and this CMS fact sheet.

Habilitative Services

2016 CMS Rule on ACAOf special significance is the provision concerning habilitative services. As urged by advocates, the final rule adopts a minimum federal definition of "habilitative services." Plans must cover "health care services and devices that help a person keep, learn, or improve skills and functioning for daily living (habilitative services). Examples include therapy for a child who is not walking or talking at the expected age. 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." Plans may not impose limits on coverage of habilitative services and devices that are less favorable than any such limits imposed on coverage of rehabilitative services and devices; and for plan years beginning on or after January 1, 2017, plans may not impose combined limits on habilitative and rehabilitative services and devices. States can have their own definitions of habilitative services as long as they are consistent with this federal definition. Insurers may no longer define habilitative services.



Also of note is a provision concerning access to medications. Quoting from the press release, the "rule will help consumers access the medications they need by improving the process by which an enrollee can request access to medications not included on a plan's formulary. The rule provides more detailed procedures for the standard exception process, and adds a requirement for an external review of an exception request if the health plan denies the initial request. It also clarifies that cost-sharing for drugs obtained through the exceptions process must count toward the annual limitation on cost sharing of a plan subject to the essential health benefits requirement. The rule also ensures that issuers' formularies are developed based on expert recommendations."


Provider Directories

In addition, the rule sets requirements for provider directories. Quoting from the CMS fact sheet: "We clarify that a QHP [Qualified Health Plan] issuer must publish an up-to-date, accurate, and complete provider directory, including information on which providers are accepting new patients, in a manner that is easily accessible to plan enrollees, prospective enrollees, the state, the Marketplace, HHS, and OPM. As part of this requirement, we finalize that a provider directory is considered to be easily accessible when the general public is able to view all of the current providers for a plan in a provider directory on the plan's public website through a clearly identifiable link or tab and without creating or accessing an account or entering a policy number. Additionally, issuers must also make this information available in a standard a machine readable format to provide the opportunity for third parties to create resources that aggregate information on different plans."

Out-of-Pocket Expenses

The rule also establishes total maximum out-of-pocket costs for 2016: $6,850 for individual coverage and $13,700 for family coverage. See this blog post from Health Affairs for more information on other consumer and provider provisions of the rule.