CMS proposes exchange transparency
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.