By Sabrina Corlette
The Affordable Care Act (ACA) Marketplaces simply skilled one other record-breaking enrollment season, with over 21 million individuals choosing a Marketplace well being plan for 2024. The Centers for Medicare & Medicaid Services (CMS) is rightly celebrating that accomplishment whereas working to construct on the progress and enhance the patron expertise. In November, CMS and the Treasury Department proposed a brand new set of requirements and necessities for the Marketplaces and well being insurers for plan yr 2025 by means of the annual “Notice of Benefit & Payment Parameters” (NBPP). The last rule is predicted quickly.
The proposed 2025 NBPP obtained over 200 stakeholder feedback through the public remark interval. CHIR reviewed a pattern of feedback from three main stakeholder teams to raised perceive the potential influence of the proposed guidelines. This first weblog in our three-part sequence summarizes feedback from medical health insurance corporations, their consultant associations, and brokers. The subsequent two weblog posts will summarize feedback from shopper advocacy teams and state departments of insurance coverage and state-based Marketplaces (SBM). For this publish, we reviewed feedback submitted by:
America’s Health Insurance Plans (AHIP)
Association of Community Affiliated Plans (ACAP)
Blue Cross Blue Shield Association (BCBSA)
CVS Health (previously Aetna)
The proposed 2025 NBPP covers a variety of points (an in depth abstract of its provisions, in two components, is on the market on Health Affairs Forefront right here and right here). This abstract of insurance coverage firm and dealer suggestions focuses on chosen CMS proposals: (1) The course of and requirements for states to transition and keep an SBM; (2) updates to the important well being profit (EHB) requirements*; (3) particular enrollment intervals (SEP) for low-income people; (4) insurance policies for people who fail to reconcile their premium tax credit at tax time; and (5) limits on non-standardized well being plans.
New SBM Processes and Standards
By 2026, 20 states and the District of Columbia are anticipated to function their very own SBM, with Georgia and Illinois quickly becoming a member of the present 19. Additional states, reminiscent of Michigan and Arizona, are contemplating laws to run their very own SBMs. In this proposed rule, CMS would set new expectations for states endeavor this transition, and new national-level requirements for Marketplace plans and operations.
Process for changing into an SBM
In basic, the insurers and brokers that commented on proposed course of adjustments, such because the requirement that transitioning states first spend a yr as an SBM on the federal platform, have been supportive. BCBSA and Cigna noticed that such a staged transition would give states satisfactory time to implement crucial infrastructure adjustments. HealthSherpa urged CMS to require that transitioning states doc how they might make up for enrollment losses, if they refuse to make use of the Enhanced Direct Enrollment (EDE) performance that now drives a lot of HealthCare.gov’s enrollment.
Network Standards
Health insurance coverage corporations have been much less welcoming of proposals to lift the bar for Marketplace plans by extending the federal Marketplace’s community adequacy requirements to insurers collaborating in SBMs. Of the feedback reviewed, solely Cigna expressed any assist for establishing a nationwide ground for community adequacy throughout Marketplace platforms. The firm applauded the hassle to have “more consistent and uniform requirements” for multi-state issuers. However, Cigna requested that CMS present an extra yr to implement the coverage by suspending the efficient date to January 1, 2026.
The different insurers and associations in our pattern strongly opposed extending federal time and distance requirements, arguing that state insurance coverage regulators are greatest positioned to set these requirements. “States have specialized knowledge of local geography, care patterns, and market dynamics,” AHIP commented. The commerce affiliation additional noticed that many states apply their community adequacy requirements to the complete business market, and having a separate set of federal requirements for Marketplace plans would “bifurcate” the market and create administrative complications. BCBSA had related issues, noting {that a} “one-size-fits-all” strategy would reduce insurers’ potential to “differentiate” their networks, making it tougher to supply a decrease price choice for shoppers.
Standardized plans
Health insurers equally opposed the concept of extending plans with standardized profit designs to SBMs. Here once more, insurers argued that states are “in the best position” to find out whether or not standardized plans are applicable for his or her residents (AHIP). BCBSA additional urged that SBMs be allowed to ascertain “innovative” insurance policies that meet the wants of their markets.
Web brokers and Direct Enrollment/Enhanced Direct Enrollment Entities
Noting that there’s “increased interest” amongst SBMs in using net brokers or direct enrollment (DE)/EDE entities to help with eligibility and enrollment capabilities, CMS would lengthen federal Marketplace requirements for these entities to all Marketplaces. Health insurers and brokers have been largely supportive of those proposed adjustments, with a number of exceptions.
ACAP applauded the proposal, noting that web-brokers are sometimes headquartered outdoors of the states through which they’re aiding shoppers, suggesting a necessity for a nationwide set of protections. “Standardization is a strong tool to prevent abuses,” the affiliation famous. ACAP additionally requested CMS to do extra to scale back shopper confusion with DE/EDE entities that market non-Marketplace merchandise, reminiscent of short-term restricted period insurance coverage.
Conversely, BCBSA objected to the proposal, urging as a substitute stronger CMS oversight of brokers and brokers. BCBSA identified that, for the plan yr 2023 open enrollment interval, the federal Marketplace had “large increases in unauthorized enrollments.” BCBSA noticed that in lots of instances these fraudulent enrollments, typically executed and not using a shopper’s information or consent, have been pushed by net brokers who have been out-of-state.
HealthSherpa and eHealth each typically supported the online dealer and DE/EDE proposals. eHealth famous that uniform requirements for net brokers and DE entities assist “ensure a level playing field and oversight to ensure enrollees are treated equally.” They additionally prompt that constant requirements would give shoppers extra confidence in these entities as trusted sources of eligibility and enrollment assist. HealthSherpa additionally supported new necessities that will assist forestall shoppers from inadvertently enrolling in non-Marketplace plans.
HealthSherpa and eHealth additional noticed that net brokers and DE/EDE entities now drive a lot of HealthCare.gov enrollment. In 2022, these channels accounted for 57 p.c of enrollment, and certain contributed to the numerous features of the 2024 enrollment season. To higher illuminate this influence, eHealth urged CMS to publicly launch plan choice and enrollment knowledge for EDE and DE channels on a extra common foundation.
Updates to Essential Health Benefit (EHB) Standards
The ACA requires states to bear the prices of any state profit mandates which are enacted after December 31, 2011 which are along with the EHB. At the identical time, states can choose a brand new or revised EHB-benchmark plan with out dealing with an obligation to defray the price of further advantages as long as the plan meets sure requirements. CMS has obtained suggestions from states that they’ve struggled to operationalize the “defrayal” coverage, and that some state efforts to mandate sure advantages may unintentionally be eradicating EHB protections from advantages already included within the state’s EHB-benchmark plan. States have additionally expressed concern in regards to the requirements underneath which they can change their EHB-benchmark plan. Rules promulgated for 2019 require states to fulfill two scope of profit requirements:
- The typicality normal. The plan should present advantages equal to these supplied underneath a typical employer plan.
- The generosity normal. The plan should present advantages that don’t exceed the generosity of probably the most beneficiant plan amongst a set of comparability plans.
In this draft rule, CMS proposed changes to the EHB defrayal coverage and the requirements adopted in 2019 that govern updates to the EHB-benchmark plan. In addition, the company proposed adjustments to how prescribed drugs are lined within the EHB.*
Defrayal and EHB replace adjustments
Health insurer feedback in our pattern unanimously opposed the proposal to permit state profit mandates that, if already lined by the EHB benchmark plan, wouldn’t set off a defrayal obligation. They additionally really helpful towards finalizing the proposal to eradicate the generosity take a look at when assessing states’ proposed adjustments to their EHB benchmark plans. Insurers argued that each adjustments would end in premium will increase. AHIP and BCBSA additionally decried the proposals as regulatory overreach inconsistent with the textual content of the ACA’s defrayal provision; AHIP argued that the adjustments would render the ACA’s “cost defrayal obligation a nullity,” whereas BCBSA asserted that they have been “inconsistent with [c]ongressional intent.” CVS Health additionally flagged that the proposals would create “significant financial costs with no guardrails,” and an “unprecedented level of annual volatility in EHBs.” The firm lamented the influence on employers particularly, asserting that they are going to be confronted with the troublesome option to pay increased prices or take away some profit choices.
Prescription medication in extra of EHB
CMS has proposed that if a plan covers prescribed drugs in extra of these lined by a state’s EHB benchmark plan, they might be thought of EHB. This would require well being plans and insurers to depend the price of these medication in the direction of enrollees’ annual most out-of-pocket prices and the ACA’s ban on annual and lifelong greenback limits on advantages. The well being insurers in our pattern typically opposed this proposal of their feedback. BCBSA urged CMS to additional examine the influence of such a coverage, noting that many third-party directors for employer-based plans use “copay maximizer programs” to seize affected person help {dollars} supplied by drug producers. BCBSA notes that underneath such packages, enrollees can entry medication outdoors of EHB, typically with out cost-sharing. If CMS’ proposal is finalized, well being plans would want to increase the variety of medication which are thought of EHB, making them ineligible for a copay maximizer program.
Determining what medication to cowl: proposed change in U.S. Pharmacopeia methods
To meet EHB requirements, insurers should cowl not less than the identical variety of medication in each class and sophistication as outlined underneath the United States Pharmacopeia (USP) Medicare Model Guidelines (MMG), or one drug in each class and sophistication—whichever is larger. CMS has obtained stakeholder suggestions that the USP MMG has gaps in protection, notably for weight problems, infertility, and sexual problems, and is up to date sometimes. Therefore, on this proposed rule the company sought feedback on whether or not to switch the USP MMG with the USP Drug Classification system (DC) to categorise the prescribed drugs required to be lined as EHB.
Health insurers typically opposed switching to the USP DC system. Comments famous that the extra granular USP DC system would require insurers to cowl medication with, in response to AHIP, “weak or poor evidence” of medical profit. Cigna supported switching to a brand new classification system, however the insurer argued that the USP DC may require protection of infertility medication, sexual dysfunction medication, and weight reduction medication that presently fall outdoors the EHB. Should CMS transfer ahead with this proposal, Cigna urged the company to carve out these classes as “non-EHB.”
CMS additionally sought feedback on the protection of anti-obesity medication, notably the brand new GLP-1 class of medicines. The medical health insurance corporations in our pattern have been uniformly against necessities to cowl GLP-1s. ACAP argued that the monetary prices of masking these medication would “disproportionately disadvantage” small, native plans that serve areas with a excessive incidence of weight problems. BCBSA prompt that mandates to cowl these medication mustn’t go into impact with out extra proof of their long-term medical effectiveness and medical necessity.
Consumer illustration on P&T Committees
CMS has proposed to require, starting in plan yr 2026, that insurers’ Pharmacy & Therapeutics (P&T) Committees embody not less than one shopper consultant. Health insurers unanimously expressed reservations about this proposal, citing two major issues: (1) shopper representatives would lack the required medical and technical experience required to meaningfully take part on a P&T Committee, and (2) many so-called “consumer representatives” are actually financially supported by the pharmaceutical business. If the proposal strikes ahead, insurers argued that “robust conflict of interest protections” and medical experience ought to be required.
SEPs for Low-Income Individuals
The 2022 NBPP created a month-to-month particular enrollment alternative for people at or under 150 p.c of the federal poverty stage (or $21,870 in annual earnings for a single particular person in 2023), however provided that the patron can enroll with a 0 p.c premium contribution after premium subsidies. In impact, this SEP is just out there due to briefly enhanced premium tax credit approved underneath the Inflation Reduction Act (IRA). With these subsidies slated to run out on the finish of 2025, CMS is proposing to make this low-income SEP everlasting by lifting the requirement that enrollees have a 0 p.c premium contribution.
Health insurers in our pattern opposed this coverage, arguing that making the low-income SEP everlasting would end in, as ACAP put it, “changed behavior” that will immediate antagonistic choice and elevated premiums. AHIP predicted that this SEP, if finalized would end in “constant enrollments and disenrollments,” and Cigna argued that this volatility, mixed with “the inadequacies of risk adjustment,” would deteriorate the danger pool and destabilize the Marketplaces.
Failure to Reconcile Advance Premium Tax Credits (APTCs)
CMS has proposed to require that Marketplaces give enrollees advance discover if they’re prone to shedding premium tax credit score eligibility as a result of they did not file and reconcile these tax credit on their tax return. Marketplaces must notify enrollees of this danger after one yr of failing to reconcile premium tax credit (a yr upfront of shedding these premium tax credit). The insurers in our pattern have been largely supportive of this proposal. BCBSA, for instance, noticed that buyers usually tend to keep enrolled if they’re notified earlier than they lose premium tax credit, somewhat than after the actual fact, as a result of they nonetheless have a possibility to replace their eligibility and retain monetary help.
Limits on Non-Standardized Plans
Currently, Marketplace insurers on the HealthCare.gov platform can provide solely 4 non-standardized plan choices per service space in every of the next classes:
- Product community kind;
- Metal stage (excluding catastrophic plans); and
- Inclusion of dental and/or imaginative and prescient protection.
This four-plan restrict will drop to 2 for every class for plan yr 2025 and past. In the proposed 2025 NBPP, CMS would provide an exceptions course of to permit further non-standardized plan choices for plans with decrease cost-sharing for companies that deal with persistent or excessive price situations.
Health insurers urged CMS to not transfer ahead with the two-plan restrict in 2025, arguing that doing so could be disruptive to enrollees and stifle innovation. AHIP additionally requested CMS to delay the two-plan restrict till they may consider and publish knowledge on the influence of the present four-plan restrict, together with knowledge on what number of shoppers enrolled or re-enrolled in standardized plan choices, what number of shoppers have been required to change to a brand new plan, shopper satisfaction scores, and agent and dealer suggestions on the plan limits. Oscar equally expressed concern in regards to the influence of the two-plan restrict, arguing that “crosswalking”—the method of enrolling a shopper in a brand new plan when their previous one is discontinued—is disruptive to members. The firm argued that buyers want selection in plan option to account for various well being wants and demographic elements.
The carriers typically appreciated the proposed exceptions course of however discovered it too slim. For instance, whereas ACAP agreed with CMS issues in regards to the danger of “choice paralysis” for shoppers confronted with too many plans, they urged CMS to broaden the factors underneath which carriers may request an exception. Several of the insurers in our pattern prompt exceptions for plans based mostly on elements reminiscent of completely different supplier networks or formularies, HSA eligibility, lowered cost-sharing for telehealth, or digital major care.
*Stakeholder feedback on one other CMS proposal to ease states’ potential so as to add grownup dental companies to the EHB benchmark plan, will probably be mentioned in a separate, forthcoming weblog publish.
A Note on Our Methodology
This weblog is meant to offer a abstract of feedback submitted by insurance coverage corporations, consultant associations, and brokers. This isn’t meant to be a complete assessment of all feedback on each provision within the proposed 2025 NBPP, nor does it seize each part of the reviewed feedback. To view extra stakeholder feedback, please go to https://www.regulations.gov/.