On February 29th, CMS published its final rule regarding the 2017 benefit and payment parameters for the Federally-facilitated health insurance exchanges. As part of the final rule, CMS creates standardized health care plans that insurers can offer on the exchanges.
CMS created the standardized plans in order to simplify health insurance shopping for consumers. According to the final rule, a standardized health care plan is a qualified health care plan with a cost-sharing structure defined by HHS. Each standardized plan has a fixed deductible, limit on annual out-of-pocket maximums, and copayment or coinsurance for the services in the plan. By standardizing certain plans, it should make it easier for consumers to compare the different issuers and their prices since the plans would otherwise be identical across all issuers that offer them.
The standardized plans exempt some services from deductible requirement, such as primary care physician visits and specialist visits. CMS determined that it would exempt these services in order to guarantee access to care, and not simply access to coverage. This would mean that a patient is only financially responsible for their copay as opposed to first exhausting their deductible. In addition, the plans would be offered to all beneficiaries across the country, regardless of any state-specific rules in place.
While optional for insurers to offer, CMS built the standardized plans using the items covered by the most popular plans at each “metal” level, except the Platinum level. Insurers are not required to offer any standardized plans and are still able to offer an unlimited number of non-standardized plans. Because of this, it is unclear how broadly issuance of standardized plans will be accepted.
The final rule goes into effect in May 2016, and will apply to the plans offered on the federally-facilitated health insurance exchanges for 2017.
Below is a summary of the primary features of each standardized plan level:
Plans and Selected Covered Services (* = Not subject to deductible)
| Bronze | Silver | Silver | Silver | Silver | Gold | |
| Deductible | $6,650 | $3,500 | $3,000 | $700 | $250 | $1,250 |
| ER Services | 50% | $400 copay | $300 copay | $150 copay | $100 copay | $250 copay |
| Inpatient Services | 50% | 20% | 20% | 20% | 5% | 20% |
| Urgent Care | 50% | $75 copay* | $75 copay* | $40 copay* | $25 copay* | $65 copay* |
| PCP Visit | $45 copay* | $30 copay* | $30 copay* | $10 copay* | $5 copay* | $20 copay* |
| Specialists | 50% | $30 copay* | $30 copay* | $10 copay* | $5 copay* | $20 copay* |
| Imaging | 50% | 20% | 20% | 20% | 5% | 20% |
| Lab Services | 50% | 20% | 20% | 20% | 5% | 20% |
| X-Rays | 50% | 20% | 20% | 20% | 5% | 20% |
| Generic Drugs | $35 copay* | $15 copay* | $10 copay* | $5 copay* | $3 copay* | $10 copay* |
| Preferred-Brand drugs | 35% | $50 copay* | $50 copay* | $25 copay* | $5 copay* | $30 copay* |
| Non-Preferred Brand drugs | 40% | $100 copay* | $100 copay* | $50 copay* | $10 copay* | $75 copay* |
| Specialty Drugs | 45% | 40%* | 40%* | 30%* | 25%* | 30%* |
