February 24, 2015

CMS Releases Exchange Rules, Application

Templates, Letter to Issuers

Last week, we saw a flurry of policy and technical guidance from the Centers for Medicare and Medicaid Services (CMS) and the Center for Consumer Information & Insurance Oversight (CCIIO) regarding carrier participation on Health Insurance Marketplaces in 2016. The following are short summaries and links to these resources. Look out for more detailed summaries in the Dental Interact (DI) Health Care Reform Open Forum.

Final Rules on Benefit and Payment Parameters for Plan Year 2016

These rules set forth payment parameters and provisions related to the risk adjustment, reinsurance, and risk corridors programs; cost sharing parameters and cost-sharing reductions; and user fees for Federally-facilitated Marketplaces (FFMs).

One item of particular interest to dental plans has been the proposed provision regarding aging off pediatric dental benefits when an enrollee turns 19. It appears the Benefit and Payment Parameters rule reversed the proposed approach to require coverage until the end of the year, and would instead require issuers to provide coverage for pediatric services until at least the end of the month in which the enrollee turns 19. CMS encourages issuers to cover services under the pediatric services EHB category beyond the 19th birthday month if non-coverage of those services after that time would negatively affect care. (page 228)

HHS Final Benefit and Payment Parameters:

Final Letter to Issuers on Participation in 2016 FFMs

The Letter provides issuers seeking to offer Qualified Health Plans (QHPs) and Stand-Alone Dental Plans (SADPs) with operational and technical guidance to help them successfully participate in FFMs and FF-Small Business Health Options Programs (FF-SHOPs).

Final Letter to Issuers:

Exchange Application Templates for PY 2016

Application and templates are available to issuers applying for certification to participate in the FFMs and include instructions, files, justifications, supporting documents and tools for issuers.

Also, CMS is continuing weekly Plan Management calls on changes to some of these templates. Registration for these calls, titled “2015 Qualified Health Plan (QHP) March Series III,” is available online at

PY 2016 Qualified Health Plan Application Instructions, Templates and Materials:







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