2015-12-09-奥纬咨询-2017_Notice_of_Benefit_and_Payment_Parameters_20页_250kb

报告摘要

Summary of HHS Notice of Benefit and Payment Parameters for 2017 (Draft Notice, November 20, 2015)

This document outlines the proposed rules and parameters for health insurance markets in 2017 under the Affordable Care Act, focusing on individual and small group markets, reinsurance, risk corridors, exchanges, and issuer standards.

A. Requirements Relating to Health Insurance Coverage

Plan year defined as per §144.103, cannot exceed 12 months.
Employer classification revised effective January 1, 2016: small employers (1-50 employees for state, up to 100 if state elects), large employers (average ≥51 employees). States may expand small employer definition.
Exceptions to rating and service areas for small group coverage raised concerns about risk pooling; HHS seeks comments on addressing this.
Student health coverage must use index rate methodology starting 2017, with no age rating factor changes proposed; separate risk pools allowed with prohibitions on risk-based factors.

B. Requirements for the Group Health Insurance Market

Exceptions proposed to guaranteed renewability for discontinuing products or coverage, aligning with availability rules.
Other group market requirements maintained.

C. Health Insurance Reform Requirements for Group and Individual Markets

Fair Health Insurance Premiums: Rating areas based on employer's principal address; potential exceptions for limited service networks. HHS seeks input on standardizing rating and service areas.
Guaranteed Availability: Issuers must provide 90 days notice for product discontinuation and 180 days for all coverage end; states may prohibit restrictions based on employer contributions if small employers expanded.
Guaranteed Renewability: Exceptions removed for non-renewal due to employer violations or association dissolution.
Student Health Insurance: Required to use 60% actuarial value plans, with no changes to affordability thresholds; rate filings for student plans solicited for comments.

D. Standards Related to Reinsurance, Risk Corridors, and Risk Adjustment

Sequestration: 6.8% for 2016 reinsurance payments, 7.0% for risk adjustment funds, available in 2017.
Permanent Risk Adjustment: Fee increases to $1.80 per enrollee per year. 2017 model recalibrated using 2012-2014 data, incorporated preventive services, affecting age-gender coefficients. Prescription data and high-cost condition treatments under review; potential partial year adjustments considered.
Transitional Reinsurance: Coinsurance adjusted upward if excess funds remain; audit authority expanded to third parties.
Temporary Risk Corridors: 2015 reporting adjusted for CSR uncertainties and unpaid claims estimates.
Data Collection: Default risk charge higher percentile (90th for 2015), penalties for data non-compliance; grace periods for explanations; direct CMPs for failures.

E. Health Insurance Issuer Rate Increases: Disclosure and Review Requirements

Rate reviews for single risk pools triggered by weighted average premium increases exceeding thresholds.
Requires unified rate review templates and actuarial memoranda for increases.

F. Exchange Establishment Standards

Definitions updated for employers on SHOP; Federal platform agreements specified for SBE-FPs.
Technical assistance phases for exchanges: declaration letters due early, blueprints approved timely for open enrollment.
Income verification thresholds flexible; eliminated sampling process.
SHOP auto-enrollment options added; appeals processes for terminations and eligibility.
Navigator training mandatory; web-brokers, agents, and approved vendors standardized with updated requirements.

G. Health Insurance Issuer Standards Under the ACA, Including Exchange-Related Rules

Standardized Options: Proposed but not mandatory for 2017: simplified plans at Bronze, Silver, Gold levels with fixed cost-sharing.
FF-SHOP User Fees: Proposed rates unchanged for 2017, with considerations for phasing in state operations.
Other issuer standards enforced through decertification if non-compliant.

H. Issuer Use of Premium Revenue: Reporting and Rebate Requirements

Includes six-month claims runout for MLR reporting; fraud prevention expenses considered.
Requirements for third-party premium payments, notification of discrepancies.

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