Health Insurance Exchange Shifts for 2016, Be Prepared for 6 Changes

As we step into a fresh 2015, as we are planning our goals and objectives for 2015 it’s interesting to remember that the health insurance open enrollment period is only 10 months away for Open Enrollment 2016.


Below are six major changes that impact consumers and Health Insurance Exchanges as we jump into 2015. Thinking ahead will help your organizations anticipate more effectively and prepare for an amazing 2016 Open Enrollment!


1. Change to 2016 Open Enrollment Dates


CMS Issued the HHS Notice of Benefit and Payment Parameters for 2016 Proposed Rule, posted November 21st, 2014. The Open Enrollment period in 2015 was November 15, 2014 through February 15, 2015. However, for the 2016 Open Enrollment period that is changing. For 2016 the rule proposes the annual Open Enrollment Period for 2016 and beyond begins on October 1 and run through December 15 of the year prior to the benefit year. Initially 2016 Open Enrollment was slated from October 15, 2015 through December, 7, 2015 to have the same dates as Medicare open enrollment, however, that since has changed.


2. Telephonic Support Expanded

The above rulemaking also proposes to improve meaningful access standards by requiring that all Marketplaces, QHP issuers, and web-based health insurance brokers provide telephonic interpreter services in at least 150 languages in addition to the existing requirement of providing language services.


3. Auto-Enrollment for 2016

The rule takes steps to help consumers keep their premiums low. Under current rules, consumers who do not take action during the open enrollment window are generally re-enrolled in the same or similar plan they were in the previous year, even if that plan experienced significant premium increases. Under these proposed rules, CMS is considering giving consumers the option of being defaulted into a lower cost plan rather than their current plan. This will mean changes for Exchanges to re-align their notification, consumer letters, and auto-enrollment business and technical processes.


4. The IRS 1095-A


Consumer View

When a consumer files income taxes for 2014, they will be asked whether they have had health insurance. Unless they qualify for an exemption, if you don’t have coverage you’ll have to pay a penalty.

                The fee for not having coverage in 2014 (the higher of these two methods):

  • 1% of your yearly household income.


  • $95 per person for the year ($47.50 per child under 18). The maximum penalty per family using this method is $285.


The fee for not having coverage in 2015 (the higher of these two methods):

  • 2% of your yearly household income.
  • $325 per person for the year ($162.50 per child under 18). The maximum penalty per family using this method is $975.


Each taxpayer or responsible adult who enrolled, or whose family member enrolled” in an exchange QHP would get a summary of the information going to the IRS on a new form, the Form 1095-A.


Exchange View

The IRS has proposed the rules exchanges would use to report on consumer tax credit eligibility to the IRS and tell the consumers what information was flowing to the IRS.


Each taxpayer or responsible adult who enrolled ,or whose family member enrolled” in an exchange for “qualified health plans’ {QHP} would get a summary of the information going to the IRS in a new form, the Form 1095-A. The form would be sent on or before January 31, starting January 31, 2015. This means Exchanges need to have letters into the mail for their members by end of January.



5. Changes to Summary of Benefits and Coverage (SBC)

The Departments of Health and Human Services, Labor, and the Treasury December 22, 2014 issued proposed rules to help people who are shopping for health insurance coverage better understand their options by expanding the existing Summary of Benefits and Coverage presented to consumers.


All health plans and issuers are required to provide consumers with a standardized, brief summary of what a health insurance policy or employer plan covers. This information allows consumers to make “apples to apples” comparisons when they are shopping for health insurance coverage, and to have a clear summary of what their insurance covers.


The proposed rules would add an additional coverage example that shows cost-sharing related to a broken foot, to help consumers understand what their plan would cover in an emergency scenario. The Departments are also proposing to update the pricing data used in the coverage examples so that the examples reflect more accurate charges experienced by consumers.


The proposed rules would also significantly streamline and shorten the form by removing information that is not required by statute and has been identified through consumer testing to be less relevant for consumers purchasing health insurance


If finalized, the new requirements would be implemented for plan years on or after Sept. 1, 2015.


To view the proposed rules, visit:

6. Exchange Must Display Quality Standards on Their Website

In the Patient Protection and Affordable Care Act; Exchange and Insurance Market Standards for 2015 and Beyond (Final Rule), the ICRs Regarding Quality Standards for Exchanges (§§155.1400 and 155.1405), direct that each Exchange must display, on its website, quality rating and ESS result information for QHPs offered on the Exchange. Additionally, in §155.410 Initial and annual open enrollment periods it defines updated notice requirements for open enrollment periods. Specifically in section (d) it states, “Notice of annual open enrollment period. Starting in 2014, the Exchange must provide a written annual open enrollment notification to each enrollee no earlier than the first day of the month before the open enrollment period begins and no later than the first day of the open enrollment period.”


The result is a required website update adding quality information for all QHPs offered on the Exchange and new batch and notices updates.


The effective date of this Final rule is October 1, 2014.


Plan early to align your organizations for the known and the unknown changes that are likely to develop as we make our way into 2015.

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Peter is a technology executive with over 20 years of experience, dedicated to driving innovation, digital transformation, leadership, and data in business. He helps organizations connect strategy to execution to maximize company performance. He has been recognized for Digital Innovation by CIO 100, MIT Sloan, Computerworld, and the Project Management Institute. As Managing Director at OROCA Innovations, Peter leads the CXO advisory services practice, driving digital strategies. Peter was honored as an MIT Sloan CIO Leadership Award Finalist in 2015 and is a regular contributor to on innovation. Peter has led businesses through complex changes, including the adoption of data-first approaches for portfolio management, lean six sigma for operational excellence, departmental transformations, process improvements, maximizing team performance, designing new IT operating models, digitizing platforms, leading large-scale mission-critical technology deployments, product management, agile methodologies, and building high-performance teams. As Chief Information Officer, Peter was responsible for Connecticut’s Health Insurance Exchange’s (HIX) industry-leading digital platform transforming consumerism and retail-oriented services for the health insurance industry. Peter championed the Connecticut marketplace digital implementation with a transformational cloud-based SaaS platform and mobile application recognized as a 2014 PMI Project of the Year Award finalist, CIO 100, and awards for best digital services, API, and platform. He also received a lifetime achievement award for leadership and digital transformation, honored as a 2016 Computerworld Premier 100 IT Leader. Peter is the author of Learning Intelligence: Expand Thinking. Absorb Alternative. Unlock Possibilities (2017), which Marshall Goldsmith, author of the New York Times No. 1 bestseller Triggers, calls "a must-read for any leader wanting to compete in the innovation-powered landscape of today." Peter also authored The Power of Blockchain for Healthcare: How Blockchain Will Ignite The Future of Healthcare (2017), the first book to explore the vast opportunities for blockchain to transform the patient experience. Peter has a B.S. in C.I.S from Bentley University and an MBA from Quinnipiac University, where he graduated Summa Cum Laude. He earned his PMP® in 2001 and is a certified Six Sigma Master Black Belt, Masters in Business Relationship Management (MBRM) and Certified Scrum Master. As a Commercial Rated Aviation Pilot and Master Scuba Diver, Peter understands first hand, how to anticipate change and lead boldly.