The Centers for Medicare and Medicaid Services (CMS) has released a final rule on Exchange and Insurance Market Standards for 2015, and claims it is designed to give “consumers additional tools to evaluate their options and find plans that best meet their needs and budget.” According to a news release from the American Physical Therapy Association (APTA), the new rule covers a wide range of issues, including consumer notices, state restrictions on navigators, cost sharing, and the Small Business Health Options Program (SHOP). The changes will be implemented beginning in 2015.

The new CMS rule indicates that for 2015, the maximum annual limit on cost sharing will be $6,600 for individual coverage and $13,200 for family coverage. In addition, the new rule requires issuers to utilize standardized notices when renewing coverage or discontinuing products, and addresses when insurance plans can modify coverage as well as when the modification constitutes termination of coverage. SHOP exchange rules will be modified to provide for an annual open enrollment period for all SHOPs aligned with the open enrollment period for the individual market, as indicated on the APTA news release.

The final CMS rule also provides additional guidance on the exchange quality reporting system. The APTA news release notes that a number of state exchanges already report quality information on qualified health plans (QHPs), and the federal exchange intends to begin doing so in 2016 for the 2017 coverage year. Per the new rule, the Department of Health and Human Services (HHS) will be able to consult and share information regarding QHP insurers with other state and federal regulatory and enforcement agencies as needed.

The new rule also clarifies situations under which state restrictions of consumer assistance personnel are pre-empted by federal law and imposes new federal restrictions on the consumer assistance personnel. It also authorizes civil money penalties on those who violate their federal obligations, assist in enrollment fraud, or breach the confidentiality of patient information.

The summary of the rule is available for download here:

[Source: APTA]