Proposed Regulations on 2017 Benefit and Payment Parameters

On November 20, the Department of Health and Human Services (HHS) issued proposed regulations that address a wide range of Affordable Care Act (ACA) benefit provisions that will be effective for 2017 plan years. Published each fall, these rules will be finalized in the spring for the following year.

Here is an overview of some of the key provisions in the proposed regulations.

  • 2017 Out-of-Pocket Maximums
    • The proposed 2017 annual out-of-pocket maximums are $7,150 for individual coverage and $14,300 for family coverage.
  • 2017 Marketplace Enrollment Period
    • The 2017 enrollment period will follow the same timing as 2016 enrollment: November 1, 2016 through January 31, 2017.
    • With this proposed rule, changes pertaining to re-enrollment may occur if the plan the patient is enrolled on is no longer available. Rather than becoming enrolled in a different metal of the same product, they’ll be enrolled in the same medal of the most similar plan issued by the insurer.
  • 2017 User Fee
    • The fee insurers pay to sell individual policies through the Marketplace will remain at 3.5% of the monthly premium.
  • Network Adequacy Standards
    • The rules propose several changes related to network adequacy requirements for plans sold on the Marketplace.
    • Individuals need at least 10 days notice before out-of-network expenses get treated as in-network expenses.
    • If the notice is not provided, the individual would be allowed to count the out-of-network cost sharing against his or her in-network out-of-pocket maximum.
    • Changes are also coming to standards for network coverage. These standards would cover factors such as consumer travel time and distance to providers.
  • Coverage when a provider leaves the network
    • Insurers would have to provide 30 days’ notice before discontinuing a network provider.
    • If an individual is receiving active treatment, the insurer would have to cover continuing care for up to 90 days or until treatment is completed.
  • Standardized Plan Options in the Individual Marketplace
    • To make it easier for consumers to compare costs for similar plans offered by different insurers in the federal Marketplace, certain plans will be designated as standardized plans.
    • The current proposal includes four silver, one bronze and one gold plan. Insurers can choose to offer standardized plans, non-standardized plans or both.
    • The standardized plans would have:
      • Standard deductible amount
      • Four-tier drug formularies
      • Only one in-network provider tier
      • Some services, such as office visits, urgent care and generic drugs, not subject to the deductible
      • A preference for copayments over coinsurance
  • New Model for State/Federal Partnerships
    • State Marketplaces that use’s technology for eligibility and enrollment will be known as state-based exchanges on the federal platform.
    • States will retain primary responsibility for plan management and consumer assistance while using the federal enrollment system, including certain call center services.
    • This model is intended to make the transition easier should additional states decide to move to in the future.
  • Marketplace Enrollment Directly on Insurer’s Websites
    • The proposed rules request comments on standards that would allow insurers and web-brokers to directly enroll individuals in the Marketplace while remaining on their own website.
  • Changes to Federally-Facilitated SHOP Plans
    • HHS proposes a new employee choice option on the SHOP Marketplace for small employers.
    • Employers can currently offer their employees a single plan or the choice of plans within a metal level.

Many Californians are overwhelmed by the task of figuring out the new affordable care acts and how to maximize the benefits for your family. As your agent, we can help. Email us at or receive a free premium quote. We will make sure that we find you and your family an affordable health plan in California for 2016.