CCIIO Clarifies Non-Discrimination Requirements in Letter to Health Plan Issuers
In its annual draft guidance outlining the criteria and requirements by which health insurance plans can be certified to provide coverage through Healthcare.gov, the Center for Consumer Information and Insurance Oversight (CCIIO) has provided clarification on its standards for non-discrimination in plan design, network adequacy, and contracting with “essential community providers.”
The guidance, known as the 2016 Call Letter, covers a wide range of topics; click here to view the full letter. QHPs must submit their initial application from March 16-April 15, 2015, and certification decisions will be finalized by September 15, 2015 for the 2016 plan year.
Discriminatory benefit design: Noting that enforcement of this standard is largely states’ purview, CCIIO says it encourages states that are enforcing the Affordable Care Act to consider a number of strategies for assessing compliance with the law’s non-discrimination requirements.
Of most importance for community mental health and addiction treatment providers, CCIIO cautions plan issuers to “avoid discouraging enrollment of individuals with chronic health needs,” citing as an example coverage of extended-release drug regimens that are just as effective as multi-tablet regimens in the treatment of a condition: if a plan issuer refuses to cover such a treatment (or other similar examples), it is effectively discriminating against individuals with chronic conditions who could benefit from the treatment.
CCIIO also elaborates that if a plan issuer places most or all drugs that treat a specific condition on the highest cost tiers within their formulary, this constitutes discrimination against enrollees with chronic conditions. The National Council, with other national health care organizations, has been working to raise awareness of plans’ widespread use of formulary tiers to restrict access to most or all medications used to treat certain conditions such as mental illness, HIV/AIDS, or cancer. We applaud the proposed CCIIO guidance and the agency’s stated plan to conduct health plan formulary reviews. We encourage states and the federal government to closely monitor plans for noncompliance with these standards.
Network adequacy: For 2016 QHP certification and recertification in FFMs, CCIIO will continue to use a “reasonable access” standard to “identify networks that fail to provide access without unreasonable delay, consistent with [regulatory] requirements.” The agency notes it will analyze issuer-submitted data and will focus “most closely on those areas which have historically raised network adequacy concerns,” such as with hospital systems and mental health, oncology, primary care and dental (if applicable) providers. See a discussion on p. 21-22.
Essential community providers (ECPs): Similar to 2015, CCIIO requires QHPs to contract with at least 30 percent of available ECPs in each plan’s service area. Previous guidance states that although community mental health and addiction treatment providers do not fall within the definition of an ECP, health plans may count them against their 30 percent quota. The National Council continues to support the inclusion of community behavioral health organizations as ECPs; for a template comment letter that your organization can use to request that CCIIO make this change, click here.