Final rule requires insurers to standardize plan options in the ACA marketplace

Photo: HealthCare.gov

In the Notice of Benefit and Payment Parameters for 2023 Final Rule released today, the Centers for Medicare and Medicaid Services is finalizing standards for issuers and insurers in the Affordable Care Act marketplaces, as well as requirements for agents, brokers, web-brokers and those assisting consumers with enrollment.

The final rule seeks to strengthen the coverage offered by qualified health plans, with the aim of ensuring consumers can more easily find affordable coverage on HealthCare.gov.

CMS said these measures set the landscape for the upcoming HealthCare.gov open enrollment period, which begins on November 1.

WHY THIS MATTERS

The 2023 Notice of Benefits and Payment Parameters Final Rule makes regulatory changes in the individual and small group health insurance markets. It establishes parameters and requirements to design plans and set rates for the 2023 plan year. The rule also includes regulatory standards. Major policies include:

Advancing standardized plan options

The rule establishes standardized plan options including standardized maximum out-of-pocket limitations, deductibles and cost-sharing. These features will allow consumers to more directly compare other plan attributes, such as premiums, provider networks, prescription drug coverage and quality ratings when choosing a plan.

These standardized plan options expand the availability of coverage for services before consumers meet their deductibles, which will make it easier to access important services, CMS said. They also include simpler cost-sharing structures that will allow consumers to more easily understand their coverage. 

Issuers will be required to offer standardized plan options at every network type, at every metal level (Bronze, Silver, Gold and Platinum) and throughout every service area where non-standardized options are offered starting in 2023. 

These plans will be differentially displayed on HealthCare.gov to help consumers make more informed choices about their coverage.

Implementing new network adequacy requirements

The rule requires QHPs on the federally-facilitated marketplace to ensure that certain classes of providers are available within required time and distance parameters. For example, a plan will be required to ensure that its provider network includes a primary care provider within ten minutes of travel and a distance of five miles for enrollees in a large metro county. 

The rule also sets a standard, starting in the 2024 plan year, requiring plans to ensure that providers meet minimum appointment wait time standards. QHPs will be required to ensure that routine primary care appointments are available within 15 business days of an enrollee's request. 
Additionally, HHS will review additional specialties for time (i.e. the time it takes the enrollee to get an appointment) and distance (i.e. the distance between the provider and enrollee), including emergency medicine, outpatient clinical behavioral health, pediatric primary care, and urgent care. OB/GYN parameters will also be aligned with the parameters for primary care.

Increasing the value of coverage for consumers

Under the rule, CMS is updating the allowable range in metal coverage levels for non-grandfathered individual and small group market plans. This change will likely require some plans to increase the generosity of their coverage, making it more comprehensive and at a lower cost for many consumers. In addition, these changes will make it easier for consumers to compare plans at the various coverage metal levels and distinguish between the plan offerings.

Increasing access for consumers and removing barriers to coverage

The final rule aims to protect consumers from discriminatory practices related to the coverage of the essential health benefits by refining the CMS nondiscrimination policy. Specifically, a benefit design that limits coverage for an essential health benefit on a basis protected from discrimination under this rule (such as age and health condition) must be clinically-based to be considered nondiscriminatory. 

The rule also updates Quality Improvement Strategy Standards to require issuers to address health and healthcare disparities.

Expanding access to essential community providers

Under the final rule, for 2023 and beyond, CMS is increasing the Essential Community Provider threshold from 20% to 35% of available community providers in each plan's service area to participate in the plan's network. The higher threshold will increase access to a variety of providers for consumers who are low income or medically underserved. 

CMS anticipates that most issuers will easily meet the 35% threshold – for 2021, 80% of plans already met this standard.

Further streamlining HealthCare.gov operations

The rule sets the federal and state-based marketplaces on the federal platform user fees for 2023 at the same level as 2022. Maintaining user fees at the 2022 level will ensure adequate funding for essential marketplace functions such as consumer outreach and education, eligibility determinations and enrollment process activities. 

CMS finalizes two of the three proposed model specification changes to the risk adjustment models, improving risk prediction for the lowest and highest risk enrollees.

THE LARGER TREND

CMS is setting these standards to meet President Biden's call to strengthen the ACA, which was signed into law while he was vice president under President Barack Obama. The Biden Administration has been taking steps to get more people enrolled and covered, such as fixing the "family glitch" that prevented some working adults from enrolling family members due to the expense, and extending the open enrollment season.

At the same time, House Democrats are calling upon the Department of Health and Human Services to end so-called "junk plans" that were put into place under President Donald Trump. These plans can deny coverage for pre-existing conditions and do not have to follow other consumer protections under the ACA.

ON THE RECORD

"The Affordable Care Act has successfully expanded coverage and provided hundreds of health plans for consumers to choose from," said HHS Secretary Xavier Becerra. "By including new standardized plan options on HealthCare.gov, we are making it even easier for consumers to compare quality and value across healthcare plans."

"The recent open enrollment period demonstrated the demand for high-quality, affordable health coverage. These steps increase the value of healthcare coverage on HealthCare.gov and further strengthen the health insurance marketplace," said CMS Administrator Chiquita Brooks-LaSure. 

Twitter: @SusanJMorse
Email the writer: susan.morse@himssmedia.com