March 09, 2016

Final Rule on Health Plan Standards for 2017

Last week the Centers for Medicare and Medicaid Services (CMS) released its final "Notice of Payment and Benefit Parameters" for 2017, which sets standards for Qualified Health Plans (QHPs) sold in the Federal Facilitated Marketplace (FFM, at While the final rule includes some provisions that will be helpful to consumers, it does not include a provision that had been included in its proposed rule, and that consumer advocates had strongly supported; the final rule does not impose minimum quantitative network adequacy standards (time and distance limits) for health plans. Rather, it will continue to use the "reasonable access" standards that it has applied in the past. The change from the proposed rule is attributed to the push-back that CMS received from health plans and state regulators, which prefer that states be given time to adopt the recently developed model law from the National Association of Insurance Commissioners. The final rule does include the following provisions, among others:

  • Out of pocket maximums. In 2017, the maximum out-of-pocket costs for consumers will increase to $7,150 for an individual and $14,300 for a family.
  • "Surprise billing." Beginning in 2018, insurance issuers must count cost sharing for certain out-of-network services provided by an ancillary provider at an in-network facility towards the enrollee's annual limitation on cost sharing. But there is an exception to this requirement if the issuer provides a written notice to the enrollee that an out-of-network ancillary provider may be providing services, and that the enrollee may thus incur additional costs, within the time frame that the issuer would typically respond to a prior authorization request or 48 hours prior to the provision of the service, whichever is longer.
  • Continuity of Care. (1) Insurance issuers must provide notice of the discontinuation of a provider in its plan to all enrollees who are patients seen on a regular basis by the provider or receive primary care from the provider. Such notice must be provided 30 days prior to the effective date of the change or as soon as practical. (2) In cases where a provider is terminated without cause, insurance issuers must allow enrollees "in active treatment" to continue treatment until the treatment is complete or for 90 days (whichever is shorter) at in-network cost-sharing rates.
  • Standardized Options. To simplify the shopping experience for consumers, CMS will establish "standardized options" with respect to plans' degree of cost-sharing for different "metal levels" of plans (gold, silver and bronze). It will be optional for issuers to offer these standardized options, however. CMS is carrying out consumer testing to determine how such plans will be displayed on
  • Network Adequacy (breadth). With the goal of starting in 2017, will provide a rating of each QHP's relative network size. This summary measure will be developed by comparing the breadth of the QHP network at the plan level to the breadth of the other plan networks for plans available in the same geographic area.
  • Third-party premium assistance. CMS did not determine whether QHPs must accept third-party premium assistance from nonprofit charities, as they are now required to do from federal and state health care programs. It indicated that it would consider the issue for future rulemaking.
  • Future open enrollment periods. For 2017 and 2018, the open enrollment periods will run from November 1 to January 31. In subsequent years, it will run only from November 1 to December15.

The final Notice of Benefit and Payment Parameters for 2017 can be found in the Federal Register at, or at  (539 pp double-spaced).

For more information, see:

CMS Press Release (includes links to related rules and guidance, including Letter to Issuers)

CMS Fact Sheet on the final Notice of Benefit and Payment Parameters for 2017

Modern Healthcare article

New York Times article