Federal health officials Friday proposed changes to the rules for health coverage sold through insurance exchanges, including a possible floor for how many doctors and other providers each plan must include.
The proposals, released by the Health and Human Services Department, come as the third enrollment season is underway in the federal and state exchanges for people choosing coverage for the coming year. The draft rules, an annual ACA ritual, will begin a debate about what guidelines insurers will have to follow to sell exchange policies for 2017. Most of the changes would move those health plans in the direction of greater regulation and more consumer protections.
They would not reverse the basic elements required of the plans — such as a set of essential covered benefits — but could make a substantial difference to some people.
For instance, one change would allow patients to count all medical expenditures toward the law’s ceiling on out-of-pocket costs, even if some care was incurred outside of a plan’s network of covered services. Patients could count such spending toward that ceiling if they were not told in advance that a doctor or medical facility was outside their network.
Consumer advocates have pushed for this change. They say patients can get stuck with large bills if, for instance, they seek care at a hospital that is part of their insurer’s network and are treated while there by a doctor who is not in the network. Insurers are likely to oppose the idea.
Health insurers and health- policy analysts immediately began to wade through the voluminous regulatory language that spells out the actual details.
Caroline Pearson, senior vice president at the consulting firm Avalere Health, said that the proposals reflect “an aggressive move to strengthen regulation of the market” in the three dozen states that rely on the federal insurance exchange. Some of the rules also would apply in other states that have created their own exchanges under the ACA.
Although several changes would benefit consumers, Pearson said they still “are sort of worrisome,” given signs that the number of insurers taking part in the exchanges may be unstable. The nation’s largest insurer, UnitedHealth Group, made a surprise announcement Thursday that it has been losing so much money on exchange health plans in 23 states that it is halting marketing efforts to enroll people for the coming year — and is debating whether to pull out entirely in 2017.
One aspect of the proposed rules addresses a concern that has roiled parts of the health insurance industry since HHS announced that it was unable to pay more than 13 percent of the money it owes under an ACA provision intended to help offset the expenses of carriers with a large share of customers needing expensive care.
The proposal does not provide a new source of money for those payments, but it would tweak the method used to calculate how much money each insurer needs to pay or is owed under a related program also intended to ease the burden on insurers with big pools of sick patients.
