The Affordable Care Act (ACA) just lately celebrated its 13th anniversary with historic enrollment development within the medical insurance Marketplaces and the lowest-ever recorded uninsured charge. With the dual targets of constructing on the enrollment positive aspects and bettering the buyer expertise, the Centers for Medicare & Medicaid Services (CMS) has proposed an annual set of necessities and requirements for the Marketplaces and well being insurers for plan 12 months 2024. The draft rule, referred to as the “Notice of Benefit & Payment Parameters,” was revealed in early December, and the ultimate rule is anticipated quickly.
CMS’s proposals acquired a number of hundred feedback from stakeholders in the course of the public remark interval. CHIR reviewed a pattern of feedback from three stakeholder teams to higher perceive the impression of the proposed guidelines. This first weblog within the collection summarizes feedback from well being insurers and consultant associations. The subsequent two blogs will summarize feedback submitted by shopper advocates, and state departments of insurance coverage and state-based marketplaces. For this weblog put up, we reviewed feedback submitted by:
The draft Notice of Benefit & Payment Parameters covers a variety of points (an in depth abstract, in three components, is out there on Health Affairs Forefront right here, right here, and right here). However, this abstract of insurance coverage firm suggestions focuses on simply three important CMS proposals: (1) an effort to streamline shopper decision-making by lowering the variety of plans supplied; (2) rising community adequacy requirements and the illustration of important neighborhood suppliers in Marketplace plan networks; and (3) introducing an computerized re-enrollment hierarchy to assist lower-income customers entry the cost-sharing discount subsidies for which they’re eligible.
Reducing “Choice Overload”
The variety of plans obtainable to the typical Marketplace shopper has risen dramatically: from 25.9 plans in 2019 to 113.6 in 2023. This “plan choice overload” causes shopper confusion, frustration, and suboptimal plan choice. In an effort to mitigate plan alternative overload, CMS has proposed two different insurance policies to cut back the variety of plans at present being exhibited to market customers. The first would restrict Marketplace insurers to 2 non-standardized plan choices per product community sort (e.g., PPO or HMO) and metallic degree. As a substitute for capping the variety of plans, CMS proposes as a substitute reinstating the “meaningful difference” commonplace to cut back the variety of look-alike plans that insurers can supply and permit customers to obviously determine materials variations between plan traits equivalent to cost-sharing, supplier community, and plan sort. Under CMS’s proposal, merchandise in the identical “group”—by insurer, county, metallic degree, deductible integration sort, and product community sort—would want to have a deductible differential of $1,000 or extra to satisfy the significant distinction commonplace.
Most of the insurers in our pattern strongly oppose CMS’s proposal to restrict the variety of non-standardized plans to 2 per metallic degree. Several argue that buyers need to keep “choice” of protection choices. AHIP, for instance, notes that enrollees have “varying preferences, including access to high-value networks, broad access to providers, specific plans that contract with particular health systems . . . health savings account (HSA) eligibility . . . and much more.” Centene asserts that lowering the variety of non-standardized plans will probably be “very disruptive,” noting that lots of their present enrollees will lose entry to their chosen plan if the corporate was required to winnow its choices. Similarly, HCSC tasks that “hundreds of thousands” of its enrollees will probably be re-mapped into new plans that they didn’t choose. Among our pattern of insurers, solely Kaiser Permanente “strongly” helps CMS’s proposal. Indeed, the corporate recommends additional phasing non-standardized plans down from two to at least one in future years.
All of the insurers’ feedback in our pattern acknowledged that shopper alternative overload is an issue, they usually had various suggestions to deal with it. A couple of insurers would help limiting the variety of non-standardized plans to 4 or 5 (as a substitute of two). Several feedback additionally prompt adopting the significant distinction commonplace as a substitute of plan limits. However, if CMS does so, they counsel lowering the $1,000 allowable deductible differential to $500. Cigna, for instance, “recommend[s] a $500 standard to incorporate additional flexibility and options for consumers[.]” Several insurers argued that CMS may sufficiently resolve the selection overload drawback by higher shopper choice help instruments on HealthCare.gov.
Network Adequacy
CMS applied new quantitative requirements for community adequacy for federal Marketplace plans in plan 12 months 2023. For plan 12 months 2024, the company has proposed shifting ahead with new appointment wait time requirements. CMS additionally proposes a requirement for insurers within the federal Marketplace to contract with a minimum of 35 p.c of obtainable federally certified well being facilities (FQHCs) and a minimum of 35 p.c of obtainable Family Planning Providers with their service space—two classes of important neighborhood suppliers underneath present laws.
Several insurer feedback in our pattern, together with from the associations AHIP and BCBSA, ask CMS to delay implementation of appointment wait time requirements, arguing that insurers and the company want extra time for “testing,” to develop a course of for assessing appointment availability, and to operationalize knowledge assortment. (Of notice, appointment wait time requirements should not a brand new idea for a lot of Marketplace insurers—a minimum of 15 states already require them.) Insurers additionally asking CMS to enhance its present community adequacy assessment course of. Centene, for instance, asks CMS to set a timeline that “accounts for turnaround times on data submission,” and that the assessment course of “provides sufficient time for issuers to respond.”
The insurers additionally typically oppose CMS’s proposal requiring them to contract with a minimum of 35 p.c of obtainable FQHCs and Family Planning Providers. As Cigna frames it, “[m]oving from a threshold across all categories to requiring a threshold for specific categories limits issuer flexibility to account for variables such as provider shortages and distribution, enrollee population distribution, and rural access, and will make it more difficult for issuers to meet these thresholds.” Kaiser Permanente’s letter echoes this sentiment, additionally including that the proposed requirements would improve their administrative burden.
Automatic Re-enrollment
Although many low-income customers would profit from eligibility for plans with cost-sharing reductions (CSRs), many unwittingly forego these further subsidies by enrolling in a bronze plan (CSRs are solely obtainable to silver plan enrollees). To maximize take-up of CSRs, CMS has proposed enabling the Marketplaces to maneuver CSR-eligible enrollees who would in any other case be re-enrolled in a bronze-level plan to a silver-level plan, if the plan is throughout the similar community product sort with a decrease or equal premium after premium tax credit. People who should not CSR-eligible can be robotically re-enrolled of their present plan. California’s state-based market just lately applied an identical course of.
The insurers in our pattern typically oppose this proposal. BCBSA’s feedback assert that “[c]onsumers select plans for reasons beyond price, often prioritizing their insurer and reliability of their coverage, their network, their drugs, or HSA availability.” The affiliation argues that “[m]oving enrollees to a new plan without their knowledge may disrupt their care, impose tax liabilities, and erode their trust in their exchange and their health plan.” Centene, nonetheless, is extra receptive to the proposal, agreeing that it may lead to extra folks having plans with decrease out-of-pocket prices. However, the corporate urges CMS to undertake “guardrails” to forestall “unintended” penalties, and asks that the company interact in “sequential implementation” to keep away from disruption and shopper confusion. Specifically, the corporate requests that “[r]e-enrollment hierarchies . . . remain stable until requirements on non-standardized plan limits are finalized[.]” CVS equally asks that this proposal be delayed till a minimum of 2025.
A Note on Our Methodology
This weblog is meant to offer a abstract of feedback submitted by insurance coverage firms and consultant associations. This isn’t meant to be a complete assessment of all feedback on each provision within the Notice of Benefit and Payment Parameters proposed rule, nor does it seize each part of the reviewed feedback. To view extra stakeholder feedback, please go to https://www.regulations.gov/.