March 16, 2016

Mike Adelberg: What to Expect From CMS' Health Insurance Rating System

In the fall of 2016, the Centers for Medicare and Medicaid Services (CMS) will begin rating health insurance exchange health plans based on the doctors and hospitals included in their networks. Mike Adelberg, senior director for FaegreBD Consulting, told Managed Health Care Executive that the rating system reflects the agency’s desire to provide consumers with more information and encourage plan selection based on something other than low premium cost.

“Provider networks in a given county will be assessed against each other and assigned one of three designations—basic, standard or broad—based on the number of providers in its network versus its competitors in that county,” Adelberg said. “Consumers shopping for health plans will have this ranking in front of them when they select a plan—as well as other new forms of comparative information such as a plan quality rating of one to five stars.”

To prepare for CMS’ evolution toward more rigorous provider network oversight, Adelberg advised insurers to analyze their own networks—and prepare for increased scrutiny from consumers, regulators and the press. More broadly, insurers should recognize CMS’s movement toward active purchasing in the federally-run marketplaces and adjust their practices accordingly.

“With these and other complementary moves, CMS may be seeking to create a marketplace where more consumers choose a higher premium plan because it may be better in other ways,” Adelberg said.

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