CMS pro­poses ex­change trans­parency

Modern Healthcare - - NEWS - By Paul Demko

Con­sumer ad­vo­cates are cheer­ing the Obama ad­min­is­tra­tion’s pro­posal to in­crease health plans’ trans­parency around provider net­works and their flex­i­bil­ity with drug for­mu­la­ries so that ex­change cus­tomers will be bet­ter equipped to make in­formed choices and get the pre­scrip­tions they need.

To en­sure ad­e­quate ac­cess to pre­scrip­tion drugs, the CMS wants to re­quire health plans to es­tab­lish phar­macy and ther­a­peu­tics com­mit­tees that would meet at least four times a year to re­view drug for­mu­la­ries. More than half of the panel mem­bers would have to be health­care pro­fes­sion­als, with at least 20% of mem­bers free of any fi­nan­cial con­flicts.

“This is a re­ally ma­jor im­prove­ment,” said Carl Sch­mid, deputy ex­ec­u­tive di­rec­tor of the AIDS In­sti­tute, which has filed a com­plaint with the CMS charg­ing that some ex­change plans sold in Florida dis­crim­i­nate against con­sumers with HIV. “The only bad thing is that they’re not propos­ing it un­til 2017.”

The CMS also wants to re­vise the process for ex­change cus­tomers to get cov­er­age for drugs not on a health plan’s for­mu­lary list. If an in­surer re­jects a cus­tomer’s pre­scrip­tion re­quest, the en­rollee would have the right to ap­peal to an in­de­pen­dent panel.

The agency of­fered more in­sight into what might con­sti­tute dis­crim­i­na­tion on a drug for­mu­la­ries. For ex­am­ple, if a health plan places most or all drugs that treat a spe­cific con­di­tion on its high­est­cost tier, the CMS warned that de­ci­sion would likely con­sti­tute dis­crim­i­na­tion.

“There are a lot of good things in here that are in­creas­ing trans­parency and adding to ac­cess for peo­ple with chronic con­di­tions,” said Eric Gascho, as­sis­tant vice pres­i­dent of gov­ern­ment af­fairs with the Na­tional Health Coun­cil.

The CMS also is con­sid­er­ing a re­quire­ment that plans pub­lish their data on provider net­works and drug for­mu­la­ries in a “ma­chine-read­able file.” That would al­low out­side groups to ex­tract the data and use it to cre­ate tools to help con­sumers make in­formed choices.

The agency ad­di­tion­ally is ask­ing health plans to pro­vide a 30-day win­dow for new cus­tomers to make ad­just­ments to their treat­ment regi-

“This is a re­ally ma­jor im­prove­ment. The only bad thing is that they’re not propos­ing it un­til 2017.”

Carl Sch­mid, deputy ex­ec­u­tive di­rec­tor of the AIDS In­sti­tute

mens be­fore trig­ger­ing higher costs for us­ing out-of-net­work providers or higher-tier drugs.

But not all the pro­pos­als are draw­ing praise, such as the CMS’ plan to scrap its cur­rent pol­icy of au­to­mat­i­cally reen­rolling ex­change cus­tomers in the same plan for the next year if they do not make an ac­tive choice. The CMS is propos­ing that cus­tomers be moved to a dif­fer­ent though sim­i­lar plan if they would face a sig­nif­i­cant pre­mium hike by stay­ing in the same plan. Under the draft rule, state-run ex­changes could try out this pol­icy in 2016, while states us­ing the fed­eral ex­change would fol­low suit in 2017.

Kather­ine Hemp­stead, who di­rects health in­sur­ance cov­er­age ac­tiv­i­ties for the Robert Wood John­son Foun­da­tion, said sta­bil­ity may be another de­ter­mi­nant of how cus­tomers choose plans. “I have a feel­ing once the mar­ket set­tles down, more peo­ple are go­ing to want to keep their plan than switch,” she said.

Another ques­tion is a CMS pro­posal to move up the an­nual open-en­roll­ment pe­riod to run from Oct. 1 to Dec. 15, start­ing in 2016. That aligns with the typ­i­cal sign-up win­dow for em­ployer-based cov­er­age and Medi­care. But that’s also a time of year when many Amer­i­cans face eco­nomic stresses, in­clud­ing hol­i­day spend­ing, with months to go be­fore their in­come tax re­fund ar­rives.

Com­ments on the pro­posed rules are due Dec. 26.

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