2016 Exchange Parameters Includes Changes Championed by Patient Community

Washington, DC (February 24, 2015) – The National Health Council (NHC), the united voice for people with chronic diseases and disabilities, applauded the Department of Health and Human Services (HHS) for listening to its concerns and including the NHC’s proposed changes to the health insurance exchanges in its parameters for the 2016 marketplace.

“Creating the exchanges was just the first step to expanding access to health insurance, as we all know,” said NHC Executive Vice President and Chief Operating Officer Marc Boutin. “By enhancing the exchanges, the federal government recognizes that we can do even better if we keep our focus on the needs of the end user – the patient.”

In the regulations shared with insurance companies seeking to offer qualified health plans in the federally-facilitated marketplaces next year, the Centers for Medicare and Medicaid Services (CMS) announced changes that will greatly benefit people with chronic conditions by increasing access to medical services and helping them find the right insurance plans to meet their needs.

Among other things, HHS agreed with the NHC’s proposals to

Create transparency standards:

  • Requiring insurers to publish their drug formularies on a publicly available website, and exchange websites are to link directly to the formulary.
  • Requiring insurers to provide specific information about drug tier placement and utilization management directly on their formulary.
  • Requiring insurers to create publicly available, regularly updated websites to access all provider network details. Lists must include whether or not a provider is seeing new patients.

Create uniformity standards:

  • Requiring formularies and provider network lists to be available in a machine-readable file.
  • Requiring a standard, uniform process for appeals and exceptions.

Establish continuity of care requirements:

  • Encouraging continued access to medications and providers for patients who are stabilized on specific treatments when switching plans by guaranteeing access to medicines and providers for the first 30 days of a plan year, regardless as to whether the drugs are on formulary or the providers are in network.

Founded in 1920, the National Health Council (NHC) is the only organization that brings together all segments of the health community to provide a united and effective voice for the more than 133 million people living with chronic diseases and disabilities and their family caregivers. Made up of more than 100 national health-related organizations and businesses, its core membership includes the nation’s leading patient advocacy organizations, which control its governance. Other members include professional and membership associations, nonprofit organizations with an interest in health, and major pharmaceutical, health insurance, medical device, and biotechnology companies.

Additional Information:

If you have questions about these or other provisions in the 2016 CMS parameters letter, please contact:

Nancy Hughes
Cell: 703-608-9709