August 2015


Exchange Updates: HHS Considers Transparency Regs, CA Ponders Vision Option, DC Exchange Launches Provider Directory Tool & More

With updates posted almost daily, you won’t want to miss the latest news in Exchange and Affordable Care Act (ACA) implementation. Here are some of the latest updates (subscribe to the Health Care Reform Open Forum for more):


CMS Releases Proposed Transparency in Coverage Reporting by Exchange Issuers

In a Federal Register notice and Paperwork Reduction Act (PRA) notice, the Centers for Medicare and Medicaid Services (CMS) outlines how it will collect and display issuer data outlined at 45 CFR 156.220 on Transparency in Coverage Reporting. The requirement will apply for issuers of Qualified Health Plans (QHPs) and Standalone Dental Plans (SADPs), which is confirmed on page 66 of the 2016 Letter to Issuers and page 10829 of the Notice of Benefit and Payment Parameters for 2016. Further rulemaking with Treasury and the Departments of Labor (DOL) could address broader implementation of these standards for non-QHP issuers and non-grandfathered group health plans.

Regarding timing, the Benefit and Payment Parameters stated the collection and display of the required transparency information would begin for the 2016 plan year. That being said, CMS states that it will collect this information in phases over time to reduce the IT/systems burden and allow enough time for testing.

The first phase of this project will require issuers in the Federally-Facilitated Marketplaces (FFMs) and state-based Marketplaces (SBMs) that use to report on several data points included at 45 CFR 156.220. (The requirements would be phased in for other QHP issuers offering in states as part of a subsequent PRA package)

Issuers will be required to submit data through an email address established by CMS for this purpose. In addition to submitting data, issuers will be required to set up a webpage for several data points and provide that URL to CMS. For initial implementation, an issuer’s information will display separately in a landscape file available on

The following is a condensed list of the data elements to be displayed on and issuer websites. More detailed descriptions are included in the PRA notice Supporting Statement, Section IV.

  • Claims payment policies and practices: a publicly available webpage on an issuer’s website will display information on claims payment policies and practices, including:
    • Out-of-network (OON) liability and balance billing
    • Enrollee claims submission
  • The above webpage† would also include information on:
    • Grace periods and pending of claims in the grace period
    • Retroactive denials
    • Enrollee recoupment of overpayments
    • Medical necessity and prior authorization timeframes and enrollee responsibilities
    • Drug exemptions timeframes and enrollee responsibilities
    • Information of Explanations of Benefits (EOBs)
    • Coordination of Benefits (COB)
    • Issuer contact information
  • Periodic financial disclosures*: CMS will display prior calendar year issuer-level information about premiums, assets, and liabilities that the NAIC currently collects and displays, and which is currently publicly available
  • Data on enrollment*: issuer-level enrollment numbers as derived from the FFM
  • Data on rating practices*
  • Information on cost-sharing and payments for OON coverage*
  • Information on enrollee rights under ACA Title I*
  • Cost-sharing and payments for OON coverage

†Issuers could link to existing documents that provide this information or provide a few sentences explaining each topic. CMS expects issuers to update the information within 7 business days of any policy described on the webpage changing.

*CMS will be using existing data sources for this information; therefore, this will not be a new data collection.

Comments on the proposed collection are due Tuesday, October 13. CMS anticipates providing more detailed instructions on what issuers should submit and examples following the 60-day comment period.  


CMS Releases Proposed Revisions to Issuer Application Templates for PY 2017
In a Paperwork Reduction Act (PRA) notice, CMS seeks comment on proposed revisions to issuer application templates. These would be applicable for Plan Year 2017 certification and beyond.

Changes are being made to several templates including the Essential Community Provider, Plans & Benefits and Network Adequacy templates. Carriers should review the proposed changes for any possible impact to future applications.

While each change could impact how dental carriers complete the templates, we noticed one proposal that seemed to speak to dental specifically. In the Essential Community Provider template, CMS will be creating a new data field for the number of contracted DMDs and DDSs authorized by the state to independently treat and prescribe within the listed facility. According to CMS, “collecting this information will allow CMS to have more complete data from such providers.”

Screenshots of the changes are included in the PRA notice: “Appendix B – QHP Instrument Screenshots.”

Comments on the revisions are due Oct. 2.


CA: Exchange Ponders Adult Vision Benefit

Vision benefits for adults will be on the table at Thursday’s meeting of the Covered California board of directors. The board will hear the choices for expanding coverage to include vision for adults enrolled in plans through Covered California. Children up to age 18 receive those benefits now, according to Roy Kennedy, public information officer at Covered California. “We have no adult vision right now. The board will hear a proposed vision plan solution, what it might look like going forward,” Kennedy said.

There are two big sticking points to adding vision coverage, Kennedy said. It’s not listed as one of the 10 essential health benefits, so those plans that utilize tax subsidies are not eligible for vision coverage; and

the exchange can’t be used to manage non-qualified health plan programs, “which is what this would be,” Kennedy said. Colorado is the only state exchange to offer vision coverage. The fiscal framework in

Colorado will be one of the options presented at Thursday’s meeting, Kennedy said.

California Healthline:


DC: D.C. Health Exchange Launches New Tool to Make Finding a Doctor Easier

D.C. launched a new online tool to ease the task of finding a doctor that accepts plans sold on the District’s health insurance marketplace. Called the Universal Doctor Directory 1.0, the new tool available on D.C. Health Link allows consumers to search individual and family plans to figure out which doctors participate in particular plans. The directory also allows consumers to find a new doctor by ZIP code, last name or specialty and then see which marketplace insurance plans the doctor accepts.

The directory is only available on the individual marketplace but officials said future updates are expected to add the tool to the small business coverage.

Washington Business Journal:




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