On December 12, 2022, the U.S. Department of Health & Human Services (HHS) launched a proposed rule to refine and replace Plan Year 2024 requirements for well being insurers and Marketplaces beneath the Affordable Care Act (ACA). In addition to the proposed 2024 Notice of Benefit & Payment Parameters (NBPP) the company additionally launched a Fact Sheet, the 2024 Draft Letter to Issuers, the 2024 Actuarial Value Calculator and Methodology, steerage on fee parameters, and a response to Alabama’s request for danger adjustment flexibility. Comments on the proposals should be submitted by January 30, 2023.
The proposed rule builds on not too long ago applied necessities for standardized plans, community adequacy, and truthful advertising requirements. It continues this administration’s efforts to decrease administrative boundaries to enrollment and strengthen client help. It additionally contains modifications to danger adjustment, Advance Premium Tax Credit (APTC) coverage, market transitions, person charges, and different market requirements. Throughout the proposed rule and related supplies, the administration emphasizes its curiosity in enhancing well being fairness and decreasing disparities in well being protection and entry.
In this primary of three Forefront articles on the 2024 NBPP, we give attention to proposed market reforms and client help enhancements. The second and third articles give attention to proposed adjustments to the chance adjustment program, market operational requirements, and APTC insurance policies.
Standardized Plan Options
HHS is proposing “minor” updates to the standardized plan choices supplied throughout open enrollment for plan 12 months 2023. Readers will recall that the Obama administration had launched standardized plans (known as “Simple Choice” plans) for the federally facilitated marketplaces (FFM) starting in 2017, however these have been discontinued by the Trump administration within the 2019 NBPP. The Biden administration re-introduced standardized plans in its 2023 NBPP. Under that rule, issuers within the FFM and state-based marketplaces that use the federal platform (SBM-FP) are required to supply plans with standardized advantages designed by HHS at each product community sort, at each metallic stage, and all through each service space through which they provide plans within the particular person market. The relevant metallic ranges embody each expanded and non-expanded Bronze plans (“expanded” Bronze plans cowl no less than one non-preventive service pre-deductible or meet the IRS’ definition of a high-deductible well being plan and are permitted to have an actuarial worth of as much as 5 factors above the 60 % normal), Silver (for traditional Silver and for every of the three CSR variants), Gold, and Platinum plans.
HHS didn’t prolong the requirement to supply standardized plans to issuers in state-based market (SBM) states, partly as a result of eight of those states already require their very own variations of standardized plans. HHS additionally exempted issuers within the state of Oregon, an SBM-FP, as a result of that state additionally requires particular person market issuers to supply standardized plans. The 2023 rule permits issuers to proceed to supply as many non-standardized plan choices as they select.
In the 2023 NBPP, HHS created two totally different units of standardized plan designs, one set for states with their very own cost-sharing necessities for particular person market issuers complying with the legal guidelines in these states, and a second set for states with out such necessities. HHS additionally labored to design the standardized plans to be as comparable as attainable to the preferred plan designs in every state.
HHS calls the brand new standardized plans “Easy Pricing” plans and customers can apply filters on HealthCare.gov to view and evaluate solely standardized plans. Web-brokers offering Direct Enrollment (DE) and Enhanced Direct Enrollment (EDE) should additionally supply and differentially show the Easy Pricing plans per HealthCare.gov’s show, except HHS approves a request for a deviation.
For plan 12 months 2024, HHS proposes to take care of the Easy Pricing plans on HealthCare.gov, with some modest adjustments. First, HHS would now not require issuers to supply a standardized plan on the non-expanded Bronze metallic stage. The company discovered it infeasible to design a non-expanded Bronze plan that features any pre-deductible protection that meets the actuarial worth goal inside the permissible de minimis vary. They additionally observe that almost all FFM issuers selected to not supply non-expanded Bronze plans, providing solely expanded Bronze as a substitute.
HHS intends to proceed using 4 prescription drug tiers in its standardized plans, particularly: generic medication, most well-liked model medication, non-preferred model medication, and specialty medication. The company believes limiting the formulary to 4 tiers promotes comprehensible drug protection and facilitates customers’ potential to check amongst plan choices. However, they sign openness to increasing the variety of formulary tiers in future years and invite touch upon the suitable variety of drug tiers in standardized plans.
HHS has obtained stories that some issuers should not putting sure medication on the acceptable cost-sharing tiers. For instance, some issuers are together with generic medication in the popular or non-preferred cost-sharing tiers. As a consequence, the company proposes to require that issuers place all lined medication within the acceptable cost-sharing tier except there’s an “appropriate and non-discriminatory basis” for putting the drug within the specialty tier.
Limits For Non-Standardized Plan Options
HHS is proposing to restrict the variety of non-standardized plans that issuers can supply by way of the FFM or SBM-FPs to 2 per product community sort and metallic stage, per service space. For instance, beneath this rule issuers can be restricted to providing two gold HMO and two gold PPO non-standardized plans in any service space, starting in plan 12 months 2024. These limits wouldn’t prolong to plans supplied by way of SBMs or the SHOP (Small Business Health Options Program) marketplaces, nor would they apply to stand-alone dental plans (SADPs).
As a results of this proposed restrict, HHS estimates that the weighted common variety of non-standardized plan choices obtainable to customers can be diminished from 107.8 in plan 12 months 2022 to 37.2 in plan 12 months 2024. This quantity doesn’t embody the standardized plan choices. The company additional estimates that roughly 2.72 million present enrollees would have their plans discontinued because of these new limits, requiring issuers to crosswalk them into a brand new plan for 2024.
In its rulemaking for plan 12 months 2023, HHS raised issues and solicited feedback about “plan choice overload” for market customers, pointing to quite a few research which have discovered that too many well being plan selections can result in poor enrollment choices. In response, many commenters agreed that too many plan choices may end up in client confusion and frustration, with many arguing that the variety of plan selections now supplied on the marketplaces has elevated past some extent that’s productive for customers. Indeed, the variety of plans obtainable to the typical market client has grown from 25.9 in 2019 to 113.6 in 2023.
At the identical time, HHS notes that it has applied quite a lot of enhancements to the selection structure on HealthCare.gov to assist customers higher perceive and evaluate their plan choices. However, the company believes that bettering {the marketplace}’s selection structure is critical however not enough, by itself, to cut back the selection overload that buyers at present face.
An Alternative Strategy
Another solution to doubtlessly cut back client selection overload is to impose a “meaningful difference” requirement on issuers’ plan choices. The Obama administration had launched such an ordinary in 2015, however this was reversed by the Trump administration in 2019. As initially outlined, a plan was thought-about “meaningfully different” from one other plan supplied by the identical issuer if an inexpensive client would be capable to establish materials variations between plan traits reminiscent of (1) value sharing or out-of-pocket most; (2) supplier networks; (3) lined advantages; (4) plan sort; (5) HSA eligibility; or (6) self-only, non-self-only, or little one solely choices.
HHS is proposing, as an alternative choice to limiting the variety of issuers’ plan choices, to reinstate the significant distinction normal. However, they observe that many commenters and stakeholders have argued that the unique significant distinction normal was not rigorous sufficient to meaningfully cut back duplicative plan designs. As a consequence, HHS would replace the significant distinction normal. The company proposes that it could group plans by issuer ID, county, metallic stage, product community sort, and deductible integration sort, after which consider whether or not plans inside every group are meaningfully totally different, based mostly on variations in deductible quantities. Deductibles must differ by greater than $1,000 to fulfill the brand new normal.
HHS is looking for touch upon its two proposed approaches to decreasing client selection overload: (1) limiting the variety of plan choices or (2) reinstating a significant distinction normal that’s extra rigorous than the one utilized in plan years 2015-2018.
Rate And Benefit Information For QHPs
A Uniform Age-Rating And Eligibility Methodology For SADPs
HHS proposes to require that SADP issuers set their premium charges and decide plan eligibility based mostly on an enrollee’s age on the time the coverage issued or renewed, starting in 2024. To date, SADP issuers have had flexibility to resolve how an applicant or an enrollee’s age is set. The company notes that almost all of SADP issuers use a person’s age upon coverage efficient date to find out eligibility and charges and argues that that is additionally probably the most easy methodology for customers to know. The company asserts that permitting SADPs continued flexibility to charge by different strategies creates an excessive amount of complexity for each the marketplaces and customers. HHS would prolong this requirement to SADP issuers in FFM, SBM-FP, and SBM states.
Guaranteed Rates For SADPs
Since 2014, HHS has allowed SADP issuers to supply both assured or estimated charges. Under a assured charge, the SADP issuer should decide to charging the permitted charge, whereas beneath estimated charges, the enrollee should contact the issuer to search out out their remaining charge. HHS notes that this flexibility was solely made obtainable to SADP issuers within the early years of the marketplaces due to operational constraints. The company has now improved the required templates and varieties, enabling extra standardized score guidelines for dental plans. HHS thus proposes to require SADP issuers, as a situation of market certification, to submit solely assured charges. The company argues that requiring assured charges would assist forestall inaccurate determinations of APTCs for the pediatric dental portion of a client’s premium, which might primarily assist lower-income customers who qualify for APTCs. The company additionally notes that regardless that SADP issuers at present have the flexibleness to submit estimated charges, the overwhelming majority select to submit assured charges. HHS proposes to increase this requirement to SADP issuers in FFM, SBM-FP, and SBM states.
Plan And Plan Variation Marketing Name Requirements For Qualified Health Plans
In latest years, HHS has obtained complaints from customers in quite a few states about deceptive or misleading plan advertising names. The company, alongside state insurance coverage regulators, investigated and located that many plan names that embody cost-sharing or different profit particulars usually are incorrect or deceptive, based mostly on info submitted in plan paperwork. Examples of such deceptive plan names embody cost-sharing quantity limits that don’t point out that such limits are solely obtainable for a sure prescription drug or supplier community tier, greenback quantities that don’t specify what they check with, and using “HSA” within the plan title when the plan doesn’t enable the enrollee to arrange an HSA.
HHS proposes to require that advertising names for market certified well being plans (QHP) embody appropriate info and don’t embody content material that’s deceptive. To implement this, HHS would evaluation plan advertising names throughout the annual QHP certification course of, in collaboration with state regulators in FFM states. The company seeks touch upon this proposal. In explicit, they ask whether or not the company ought to set up a required format for plan advertising names, with specified components, to be used by all QHPs.
Network Adequacy
Plans That Do Not Use A Provider Network
HHS proposes to require all market plans, SADPs, and SHOP plans to make use of a community of suppliers that adjust to its community adequacy and important neighborhood supplier (ECP) necessities. If finalized, this might eradicate the exemption that applies to plans that don’t keep a supplier community. The company notes that, since 2016, just one FFM issuer has supplied a plan that doesn’t use a supplier community.
The ACA requires that market plans guarantee a “sufficient choice” of suppliers and supply info to enrollees in regards to the availability of in-network and out-of-network suppliers. The statute additionally requires that plans “include within health insurance plan networks those essential community providers, where available, that serve predominantly low-income, medically-underserved individuals.” HHS argues that plans can’t adjust to these necessities, and the company can’t successfully implement compliance, if the plan doesn’t use a supplier community. The company additionally believes that requiring use of a supplier community would higher shield customers from potential harms, reminiscent of lack of supplier entry, that may happen when a QHP doesn’t use a community. HHS seeks touch upon this proposal, together with the requirement to increase it to SADP issuers.
Appointment Wait Time Standards
Beginning in 2023, issuers providing plans on the FFM and SBM-FP should be sure that their enrollees can receive supplier companies inside a most time or distance from their houses. In its 2023 NBPP, HHS additionally required QHP issuers to fulfill minimal appointment wait time requirements however delayed implementation of that requirement to plan 12 months 2024, citing issues in regards to the compliance burden on issuers. Here, HHS places its FFM and SBM-FP issuers on discover that they have to start working with their community suppliers to gather the information wanted to evaluate appointment wait occasions and decide if their supplier community meets the wait time requirements detailed within the 2023 Letter to Issuers. HHS will start reviewing issuer attestations of compliance for plan 12 months 2024.
Essential Community Providers
In its fee discover for 2023, HHS set a brand new bar for the inclusion of important neighborhood suppliers (ECPs) in market plan networks. For plan 12 months 2023 and past, issuers within the FFM will need to have 35 % of obtainable ECPs collaborating of their plan networks, up from the 20 % threshold required in previous years. QHPs should supply a contract in good religion to no less than one supplier in every ECP class in every county within the plan’s service space. Currently, there are six classes of ECP suppliers:
- Federally Qualified Health Centers (FQHC)
- Ryan White Program Providers
- Family Planning Providers
- Indian Health Care Providers
- Inpatient Hospitals
- Other ECP Providers (outlined to incorporate Substance Use Disorder Treatment Centers, Community Mental Health Centers, Rural Health Clinics, Black Lung Clinics, Hemophilia Treatment Centers, Sexually Transmitted Disease Clinics, and Tuberculosis Clinics).
In the 2024 NBPP, HHS is proposing two modifications to its ECP requirements. First, it could create two new and distinct ECP classes: Mental Health Facilities and Substance Use Disorder (SUD) Treatment Centers. These suppliers would thus be faraway from the “Other ECP Providers” class. Creating these two new classes would require issuers to try to contract with no less than one SUD Treatment Center and no less than one Mental Health Facility. HHS would additionally add Rural Emergency Hospitals as a supplier sort within the “Other ECP Providers” class.
Second, HHS is proposing to require QHPs to contract with no less than 35 % of obtainable FQHCs and no less than 35 % of obtainable Family Planning Providers that qualify as ECPs inside the plan’s service space. This can be along with the prevailing requirement that plans have no less than 35% of all obtainable ECPs inside their service space, in-network. For 2024, HHS is specializing in FQHCs and Family Planning Providers as a result of these are the most important classes of suppliers (representing roughly 62% of all amenities on the ECP record). However, the company is contemplating including a specified minimal threshold to different ECP classes sooner or later. HHS doesn’t imagine this requirement can be troublesome for QHP issuers to fulfill, noting that of 2023 QHP issuers, 75% would already meet or exceed the 35% threshold for FQHCs and 61% would meet the edge for Family Planning suppliers.
Prohibiting Mid-Year Terminations For Dependent Children Who Reach Maximum Age
The ACA requires group well being plans and insurance coverage issuers that supply protection to dependent youngsters to permit these youngsters to remain on their mother and father’ plan till age 26. Operationally, HealthCare.gov requires issuers that cowl dependent youngsters to take care of that protection till the tip of the plan 12 months through which they flip 26. In this proposed rule, HHS would codify this requirement in regulation to offer extra readability for collaborating issuers and cut back enrollee uncertainty about their protection. This requirement would apply to plans supplied by way of the FFM and SBM-FPs. SBMs may implement an analogous rule at their possibility. The company notes that, with respect to households that obtain APTCs, {the marketplace} makes eligibility determinations for all the plan 12 months. The market will proceed to pay APTCs to the issuer, together with the portion attributable to a dependent little one, by way of the tip of the plan 12 months through which the dependent little one turns 26. If in any other case eligible, the member of the family that has turned 26 will probably be re-enrolled right into a separate coverage starting January 1 of the next plan 12 months, with any APTCs for which they’re eligible.
Establishing A Timeliness Standard For Notices Of Payment Delinquency
When a plan enrollee turns into delinquent in making premium funds, HHS requires insurers to ship a discover to the enrollee in order that they have a chance to pay unpaid premiums and keep away from a termination of their protection. In conducting oversight of issuers, the company discovered that some have been delaying sending these notices, in excessive circumstances stopping the enrollee from correcting their delinquency. HHS is thus proposing establishing a timeliness normal for these notices and asks for touch upon what an inexpensive timeframe can be.
Standards For Navigators And Other Consumer Assisters
Allowing Door-To-Door Assistance
Federal guidelines at present prohibit Navigators, licensed software counselors, and non-Navigator help suppliers (“Assisters”) from going door-to-door or utilizing unsolicited means to offer enrollment help to customers. HHS is proposing to repeal that prohibition. The company notes that it has established safeguards to make sure that Assisters are sustaining the privateness and safety of customers’ info. It additionally argues that prohibiting Assisters from going door-to-door creates boundaries for customers who should make appointments to acquire enrollment assist and imposes undue burdens on people whose journey is restricted by lack of mobility or reasonably priced transportation, or who’re immunocompromised.
Rules For Brokers And Agents
The proposed rule would set up new necessities for brokers, brokers, and web-brokers that help customers with FFM and SBM-FP enrollments. Existing federal guidelines allow HHS to droop market agreements with brokers and brokers for as much as 90 days, when there’s proof of fraud or abusive conduct. In circumstances of extreme misconduct, HHS can terminate the agent or dealer’s settlement with {the marketplace}. In each circumstances, brokers and brokers can attempt to rebut the costs towards them and restore their potential to facilitate enrollments.
Noting that the method for reviewing agent and dealer rebuttal supplies is time intensive and infrequently requires evaluation of complicated technical info and information, HHS is proposing to increase the timeframe for evaluation. Specifically, HHS is proposing to present itself as much as 45 days to evaluation rebuttal proof from brokers and brokers who’ve had their market agreements suspended, and as much as 60 days to evaluation submissions from brokers and brokers which have had their market agreements terminated.
The proposed rule would additionally require brokers, brokers, and web-brokers to doc that their shoppers (or approved representatives) have reviewed and confirmed their eligibility info earlier than they submit an software. The documentation would wish to incorporate the date the buyer reviewed the applying, the buyer’s title (or approved consultant’s title), an evidence of the attestations within the software, and the title of the agent, dealer, or web-broker offering the help. Brokers and brokers would wish to take care of this documentation for no less than 10 years and be capable to present it to HHS upon request.
HHS observes that it has obtained client complaints about brokers, brokers, or web-brokers submitting incorrect software info on their behalf. The company notes that these complaints are troublesome to research as a result of they usually contain one individual’s phrase towards one other’s. HHS believes that requiring documentation that the buyer has reviewed and confirmed their software info may assist with the adjudication and backbone of such complaints. Although HHS wouldn’t prescribe precisely how brokers, brokers, and web-brokers ought to receive the required documentation, they would offer a non-exhaustive record of acceptable strategies. The company seeks touch upon this proposal, together with info on present greatest practices among the many agent/dealer neighborhood.
The proposed rule would additionally require FFM and SBM-FP brokers, brokers, and web-brokers to doc that they’ve obtained a client’s consent to help them with a market eligibility software. This consent would wish to incorporate the date, the buyer’s title (or approved consultant), and the title of the agent, dealer, or web-broker. While the company declines to prescribe the type of consent, they observe that it may take the type of a signature or a recorded verbal authorization. The dealer, agent, or web-broker can be required to take care of a report of the consent for no less than 10 years and be capable to produce it for HHS upon request. The company notes that they’ve obtained client complaints alleging that they have been enrolled in market protection with out consent. When investigating these complaints, HHS has discovered brokers and brokers who attest to receiving consent however can’t produce dependable information to defend themselves from the allegations.
Author’s Note
The Robert Wood Johnson Foundation offered grant assist for the writer’s time researching and penning this put up.
Sabrina Corlette, “Proposed 2024 Payment Rule, Part I: Insurance Market Reforms and Consumer Assistance,” Health Affairs Forefront, December 14, 2022, https://www.healthaffairs.org/content/forefront/proposed-2024-payment-rule-part-1-insurance-market-reforms-consumer-assistance-and-risk © 2022 Health Affairs by Project HOPE – The People-to-People Health Foundation, Inc.