Reform Alert - News from the Blues' Office of National Health Reform

OPM releases multi-state plan final rule

March 13, 2013

The Office of Personnel Management has released a final rule establishing standards for multi-state plans that will be offered through the Marketplace.

The final rule largely adopts policies from the proposed rule. OPM retains its discretion under the statute to create separate standards for multi-state plans regarding rates, medical loss ratio, provider networks, and quality.  However, OPM intends to follow most state laws and requirements for qualified health plans. OPM also intends to enter into memorandums of understanding with states about the operation of the multi-state plan program.

The final rule allows the multi-state plans to choose whether to follow a particular state’s essential health benefits package or an OPM approved benchmark plan (one of the federal employees’ health benefit plan options, supplemented as needed to comply with essential health benefits and each state's mandates).  Importantly, multi-state plan programs cannot pick and choose benefit packages state to state. A multi-state plan program must choose either the state benchmark or the OPM benchmark to apply in all states the multi-state plan program serves.  Multi-state plans will have to provide coverage in the individual market in at least 31 states (in whole or part) in 2014, ramping up to all 50 states and the District of Columbia by 2017.

Is there a fee for multi-state program plans?
OPM will not impose an additional user fee in 2014 as previously proposed.  The agency reserves the right to impose a user fee, and indicates that it may do so beginning in 2015. It estimates that the user fee would be no more that 0.2 percent of premiums. The OPM user fee will be reduced from the overall Marketplace user fee, so that a portion of the user fee would be paid to OPM, and the other portion to the Marketplace.  

Do multi-state program plans have to follow network adequacy standards?
Yes. OPM stated in the final rule that the multi-state program plans will establish a uniform standard for network adequacy using time and distance standards that are based on those published by Centers for Medicare and Medicaid Services for Medicare Advantage plans (for providers and facilities) and Medicare Part D (for retail pharmacies).

Will a centralized claims data warehouse be created?
OPM is not creating a centralized data warehouse as it proposed.  

Where can I find more information?
More information can be found in the final rule (PDF).

The information in this document is based on preliminary review of the national health care reform legislation and is not intended to impart legal advice. The federal government continues to issue guidance on how the provisions of national health reform should be interpreted and applied. The impact of these reforms on individual situations may vary. This overview is intended as an educational tool only and does not replace a more rigorous review of the law’s applicability to individual circumstances and attendant legal counsel and should not be relied upon as legal or compliance advice. As required by US Treasury Regulations, we also inform you that any tax information contained in this communication is not intended to be used and cannot be used by any taxpayer to avoid penalties under the Internal Revenue Code.

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