HHS releases benefit and payment proposed rule for Affordable Care Act coverage

Photo: HealthCare.gov

As open enrollment for January 1 coverage comes to an end on Thursday, the Department of Health and Human Services has released the 2024 Notice of Benefit and Payment Parameters Proposed Rule for the Affordable Care Act.

To expand access to behavioral healthcare, the proposed rule includes two new essential community provider (ECP) categories in behavioral healthcare: Substance Use Disorder Treatment Centers and Mental Health Facilities. The rule also furthers access to providers by including a proposal to extend the current overall 35% provider participation threshold to two major ECP categories: Federally Qualified Health Centers and Family Planning Providers.

The 45-day public comment period will begin once the proposed rule is published in the Federal Register.

WHY THIS MATTERS

The proposed rule aims to increase consumer access to healthcare services, simplify choice and improve the plan selection process to make it easier to enroll in coverage, CMS said.

Proposed changes, in conjunction with a proposal to expand Network Adequacy requirements, would increase provider choice, advance health equity and expand access to care for consumers who have low income or complex or chronic healthcare conditions. It would also help those who reside in underserved areas, since these consumers are often disproportionately affected by unanticipated costs associated with provider network status and limited access to providers, CMS said.

PAYMENT PARAMETERS

CMS is issuing the 2024 benefit year premium adjustment percentage, the maximum annual limitation on cost sharing, reduced maximum annual limitation on cost sharing and the required contribution percentage (payment parameters) in guidance by January 2023, consistent with policy finalized in the 2022 Payment Notice.

CMS is proposing a risk adjustment user fee for the 2024 benefit year of $0.21 per member per month.

For the 2024 benefit year, CMS proposes to lower the user fee rate from 2.75% to 2.5% of premium for Qualified Health Plans sold on the federally-facilitated marketplace and to lower the user fee rate from 2.25% to 2% of premium for QHPs sold on the state-based exchanges. CMS anticipates these user fee rate decreases may exert downward pressure on insurance premiums, resulting in lower costs for consumers.

CMS proposes to establish and implement a required Improper Payment Pre-Testing and Assessment (IPPTA) program in calendar years 2024-2025. The proposed program would prepare state marketplaces for the planned measurement of improper payments by testing processes and procedures that support HHS's review of determinations. The program would also provide a mechanism for HHS and state marketplaces to share information that would aid in developing a measurement process in future years.

CMS proposes to change the materiality threshold for random and targeted sampling from $15 million in total annual premiums statewide to 30,000 total billable member months statewide. CMS proposes to shorten the window to confirm or dispute the findings of the Second Validation Audit to within 15 calendar days of the notification by HHS beginning with the 2022 benefit year. 

PROPOSED COVERAGE CHANGES

Under current re-enrollment processes, enrollees who are eligible for lower-priced health plans could be automatically re-enrolled in a more costly Qualified Health Plan. This rule includes a proposal that would ensure these consumers are automatically enrolled into their same plans or a lower-cost, more generous plan when available, lowering their healthcare costs by taking advantage of these savings.

The average number of plans available to consumers on the marketplace has increased from 25.9 in 2019 to 113.6 in 2023. Having too many plans to choose from can limit consumers' ability to make a meaningful selection when comparing plan offerings, CMS said. 

In response to public feedback, the rule includes proposals to make it easier for consumers to pick a health plan that best fits their needs and budget by updating designs for standardized plan options and limiting the number of non-standardized plan options offered by issuers of qualified health plans (QHPs) through the federally-facilitated marketplaces and state-based marketplaces on the federal platform.
 
The proposed rule would give the marketplaces the option to implement a new rule for the special enrollment period for people losing Medicaid or Children's Health Insurance Program (CHIP) coverage. This option would mean that consumers would have 60 days before, or 90 days after, their loss of Medicaid or CHIP coverage to select a marketplace plan. CMS believes that this new proposed special rule would help mitigate coverage gaps.

Up to 18 million people are projected to lose their Medicaid coverage at the end of the Public Health Emergency.
 
The proposed rule also changes the current coverage effective date requirements so that marketplaces have the option to offer earlier coverage effective start dates for consumers attesting to a future coverage loss. 

The proposed rule would allow assisters to conduct door-to-door enrollment to increase consumer engagement and advance health equity. Assisters currently conduct door-to-door outreach and education, and schedule follow-up appointments, but are prohibited from providing enrollment assistance upon an initial interaction at the consumers' residence. 

RISK ADJUSTMENT

Beginning with the 2023 benefit year, CMS proposes to collect and extract from issuers' EDGE servers a new data element, a Qualified Small Employer Health Reimbursement Arrangement indicator, and to extract plan ID and rating area data elements issuers have submitted to their EDGE servers from certain benefit years prior to the 2021 benefit year.

For the 2024 benefit year risk adjustment models, CMS proposes to use the 2018, 2019 and 2020 enrollee-level EDGE data for model recalibration, with the exception for the adult models' age-sex coefficients.

CMS proposes to continue to apply a market pricing adjustment to the plan liability associated with Hepatitis C drugs in the risk adjustment models for the 2024 benefit year. CMS also requests comment on whether to add a new payment Hierarchical Condition Categories for gender dysphoria to the risk adjustment models for future benefit years.

Finally, CMS proposes to repeal the ability of all states, including those prior participant states that had previously submitted a state flexibility request, to request a reduction in risk adjustment state transfers starting with the 2025 benefit year. 

CMS is soliciting comments on the requests submitted by Alabama to reduce risk adjustment state transfers by 50% in its individual (including catastrophic and non-catastrophic risk pools) and small group markets for the 2024 benefit year.

CMS proposes further refinements to HHS Risk Adjustment Data Validation (RADV). Beginning with the 2021 benefit year, CMS proposes to no longer exempt exiting issuers from adjustments to risk scores and risk adjustment transfers when they are negative error rate outliers in the applicable benefit year's HHS-RADV results. 

Finally, the agency is soliciting comments on discontinuing the use of the lifelong permanent condition list and the use of Non-EDGE Claims in HHS-RADV. 

NEW REQUIREMENTS FOR BROKERS

CMS proposes to allow HHS additional time to review evidence submitted by agents, brokers or web-brokers to rebut allegations that led to suspension of their marketplace agreements or to request reconsideration of termination of their marketplace agreements. 

For suspensions, HHS would receive an additional 15 calendar days, or a total of up to 45 calendar days, to review evidence and notify the submitting agents, brokers, or web brokers of HHS' determination regarding the suspension of their marketplace agreements. For terminations, HHS would receive an additional 30 calendar days, or a total of up to 60 calendar days.

These additional days are needed because the review process can involve parsing complex technical information and data, revisiting consumer complaints and reaching out to consumers individually, CMS said.

CMS also proposes documentation retention changes.

THE LARGER TREND

Affordable Care Act enrollment for 2023 plans has increased 18% over last year's numbers, according to CMS. An estimated 5.5 million people have selected a marketplace health plan.

CMS Administrator Chiquita Brooks-LaSure said, "Continuing to propose policies that help make it easier for consumers to choose and maintain the health coverage that best fits their needs is vital. If finalized, this proposed rule does just that."

Open enrollment began on November 1 and continues through December 15 for coverage that starts on January 1, 2023.

January 15, 2023 is the last day to enroll in or change a 2023 health plan. After this date, enrollment is available only for those who qualify for a special enrollment period.

ON THE RECORD

"The Biden-Harris Administration has taken historic action to expand access to healthcare, and the Affordable Care Act Marketplace provides millions of Americans vital coverage," said HHS Secretary Xavier Becerra. "As we make a final push now during open enrollment, we are encouraged that so many people are signing up for marketplace health plans. Already we are working to build on this success."
 

Twitter: @SusanJMorse
Email the writer: SMorse@himss.org