Today, the Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), announced new measures that will allow consumers to more easily find the right form of quality, affordable health care coverage on HealthCare.gov that best meets their needs. These measures set the landscape for the upcoming HealthCare.Gov Open Enrollment Period, which will begin on November 1, 2022, and are part of the Biden-Harris Administration’s ongoing effort to strengthen and build on the Affordable Care Act (ACA).
“The Affordable Care Act has successfully expanded coverage and provided hundreds of health plans for consumers to choose from,” said Health and Human Services 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 health care plans. The Biden-Harris Administration will continue to ensure coverage is more accessible to every American by building a more competitive, transparent, and affordable health care market.”
“The recent Open Enrollment Period demonstrated the demand for high-quality, affordable health coverage. These steps increase the value of health care coverage on HealthCare.Gov and further strengthen the health insurance Marketplace,” said CMS Administrator Chiquita Brooks-LaSure. “This policy will make it easier for people to choose the best plan that meets their needs by standardizing plan options, like maximum out-of-pocket limitations, deductibles, and cost-sharing features.”
The 2023 Notice of Benefits and Payment Parameters Final Rule (final 2023 Payment Notice) makes regulatory changes in the individual and small group health insurance markets and establishes parameters and requirements issuers need to design plans and set rates for the 2023 plan year. The rule also includes regulatory standards to help states, the Marketplaces, and health insurance companies in the individual and small group markets better serve consumers. Major policies include the following:
Advancing Standardized Plan Options
In accordance with President Biden’s Executive Order 14036 on Promoting Competition in the American Economy, the rule helps simplify the consumer shopping experience by establishing standardized plan options for issuers offering Qualified Health Plans (QHPs) on HealthCare.gov. With standardized maximum out-of-pocket limitations, deductibles, and cost-sharing features, consumers will be able to more directly compare other important 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. They also include simpler cost-sharing structures that will allow consumers to more easily understand their coverage. Issuers offering QHPs on HealthCare.gov 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 helps ensure that patients have access to the right provider, at the right time, in an accessible location. The rule requires QHPs on the Federally-facilitated Marketplace (FFM) to ensure that certain classes of providers are available within required time and distance parameters. For example, a QHP on the FFM will be required to ensure that its provider network includes a primary care provider within ten minutes and five miles for enrollees in a large metro county. The rule also sets a standard, starting in the 2024 plan year, requiring QHPs on HeathCare.gov to ensure that providers meet minimum appointment wait time standards. For example, 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 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 lower costs for many consumers. In addition, these changes will make it easier for consumers to compare plans at the various coverage metal levels (Bronze, Silver, Gold, and Platinum) 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 (EHB) by refining the CMS nondiscrimination policy. Specifically, a benefit design that limits coverage for an EHB 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 health care disparities.
Expanding Access to Essential Community Providers
Under the final rule, for Plan Year (PY) 2023 and beyond, CMS is increasing the Essential Community Provider (ECP) threshold from 20% to 35% of available ECPs in each plan’s service area to participate in the plan’s provider network. The higher ECP threshold will increase access to a variety of providers for consumers who are low-income or medically underserved. CMS anticipates that most issuers will easilymeet the 35% threshold – for PY2021, 80% of the QHPs on the FFM already met this standard.
Further Streamlining HealthCare.gov Operations
The rule sets the FFM and State-based Marketplaces on the Federal Platform (SBM-FPs) user fees for 2023 at the same level as 2022. Maintaining FFM and SBM-FPs 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 activites. 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.