The Centers for Medicare and Medicaid Services (CMS) has issued a proposed rule that places an emphasis on strengthening affordability and accessibility for insurance plans offered through the Affordable Care Act (ACA) health insurance marketplaces beginning in 2016. According to a news story from the American Physical Therapy Association (APTA), if the rule is enacted as proposed, it would in turn impact essential benefits, network adequacy, habilitative care, and cost-sharing, among other areas.

The story highlights a 324-page proposal as a key item of interest for physical therapists (PTs) and physical therapist assistants (PTAs). The document features provisions centered on essential health benefits (EHBs) and network agency standards for plans offered through the marketplace. The APTA adds that a fact sheet regarding the proposal states the new rules would protect against discrimination within health plan benefit design and provide improved transparency for consumers.

The APTA story notes that the proposed changes to EHB provisions are based upon 2012 health plans that must cover 10 EHBs, including habilitative and rehabilitative services category. Benchmark plans will proceed through 2016 in the proposed rule, and new base benchmark plans for 2017 may be selected by states. The story also says that these new plans will be based upon 2014 plans and will be adjusted to ensure they meet all EHB requirements. These requirements include prohibitions on discrimination based upon an individual’s age, expected length of life, present or predicted disability, degree of medical dependency, quality of life, or other health conditions.

The proposal also states that network adequacy requirements will not see any significant change until after the National Association of Insurance Commissioners (NAIC) issues its model act. According to the story, the proposed rule states that available out-of-network providers cannot be counted in determining network adequacy and suggests that new enrollees be allowed to use their current providers for up to 30 days after joining a plan if under an ongoing course of treatment.

According to the fact sheet, the proposed provider adequacy requirements also require up-to-date directions of providers accepting new patients, available to consumers “through a clearly identifiable link or tab and without creating or accessing an account or entering a policy number.”

The story goes on to provide a range of features of the proposed rule, including an adoption of a uniform definition of “habilitative services” in an effort to ensure adequate coverage and clarify the distinction between habilitative and rehabilitative services. Automatic hardship exemptions would be available for individuals under the age of 65 years old who live in states that have failed to expand Medicaid, have household incomes below 138% of the federal poverty level, and do not qualify for traditional Medicaid or Medicare. Cost-sharing limits for non-calendar year plans would not be allowed to be reset at the end of the calendar year, the release says.

The proposed rule is being reviewed by APTA, the story says, and the organization will provide comments to CMS.

[Source: APTA]