CMS Issues Draft Letter with 2015 Affordable Care Act Plan Certification Requirements

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On February 4, 2014, CMS released a Draft Letter containing guidance for issuers seeking to offer Qualified Health Plans (QHPs) in Federally-Facilitated Marketplaces (FFMs).  The Draft Letter offers operational and technical guidance to issuers for participation in FFMs.

In the Draft Letter, CMS notes that it intends to propose in rulemaking that applications for QHP certification adhere to certain Essential Community Providers (ECP) standards.  For certification year 2015, CMS intends to utilize a general ECP standard whereby an application would have to demonstrate that at least 30% of the available ECPs in each plan’s service area participate in the provider network.

The Draft Letter also contains information on how CMS will review issuer compliance with patient safety standards for purposes of QHP certification and recertification if the proposed 2015 Payment Notice is finalized as proposed.  Specifically, CMS has already proposed that QHP issuers who contract with a hospital with 50 or more beds be required to verify that the hospital meets certain requirements.  Additionally, CMS has proposed that QHP issuers be required to collect and maintain documentation of the CMS Certification Numbers (CCNs) from their applicable network hospitals.

CMS also describes intended revisions to the prescription drug benefit portion of the application process for 2015.  Among these proposals is a process for issuers to indicate whether a drug is considered a “medical drug” covered under a plan’s medical benefit.  CMS believes this revision would provide greater clarity with respect to how drugs are covered and paid while ensuring that medical benefit drugs are taken into account when evaluating potential QHPs for compliance with 45 C.F.R. § 156.122.  The Draft Letter also notes that CMS intends to propose through rulemaking that marketplaces may require that issuers temporarily cover non-formulary drugs (including drugs that are on the issuer’s formulary but require prior authorization or step therapy) as if they were on the issuer’s formulary during the first 30 days of coverage for coverage beginning on January 1 of each year, starting with the 2015 plan year.

Comments are due by February 25, 2014.  However, CMS notes that, to the extent that the Draft Letter merely summarizes policies proposed through other rulemaking processes that have not been finalized, issuers have already had or will have the opportunity to comment through those ongoing rulemaking processes.  The Draft Letter is available here.

Reporter, Isabella Edmundson, Atlanta, +1 404 572 3527, iedmundson@kslaw.com.