By Rachel Schwab
The Biden administration has proposed new guidelines for the Affordable Care Act’s (ACA) marketplaces in 2024. The annual regulatory bundle, generally known as the Notice of Benefit and Payment Parameters (NBPP), is anticipated to be finalized any day.
To perceive the implications of the proposals for the 2024 plan yr, CHIR has reviewed a pattern of feedback from three stakeholder teams. After reviewing feedback from insurers and client advocates within the first two components of the collection, this third and remaining weblog discusses feedback from the next state departments of insurance coverage (DOIs) and state-based marketplaces (SBMs):
A 3-part abstract of the main proposals within the NBPP from Health Affairs Forefront could be discovered right here, right here, and right here. This weblog will concentrate on feedback concerning a couple of of the Centers for Medicare & Medicaid’s (CMS) proposals that impression state officers and the customers they serve.
Auto Re-Enrollment
A majority of Marketplace enrollees are routinely re-enrolled into protection in the course of the annual open enrollment interval, quite than actively deciding on a plan. Currently, CMS’s re-enrollment “hierarchy” both retains people in the identical certified well being plan (QHP) or, if that QHP is now not out there, right into a plan at the same metallic degree. Based on considerations about sub-optimal plan alternatives, CMS has proposed permitting Marketplaces to maneuver bronze enrollees eligible for cost-sharing discount subsidies (CSRs) into qualifying silver-level plans—with the identical or a decrease premium and with comparable supplier networks—to allow them to benefit from decrease price sharing. CMS additionally sought touch upon future modifications to the re-enrollment “hierarchy,” equivalent to accounting for complete out-of-pocket prices and internet premiums when transferring customers to new merchandise.
Most states in our pattern help the proposed modifications to auto re-enrollment insurance policies for 2024. California’s Marketplace, which has an current coverage to maneuver CSR-eligible bronze enrollees into silver-level plans, applauds CMS’s proposal as “creat[ing] more opportunities to connect enrollees to higher value plans.” Similarly, Rhode Island’s Marketplace approves of the proposal to permit auto-renewal of CSR-eligible enrollees into silver plans, noting the significance of guiding enrollees to plans that meet their cost-sharing wants whereas they’ve entry to enhanced premium subsidies. New Mexico’s Marketplace describes the benefits of auto-enrolling sure customers into CSR-compatible silver plans, citing advantages for individuals who face difficulties getting each protection and care, equivalent to sure minority and immigrant populations. However, a number of Marketplaces voicing help for the proposal additionally emphasize the significance of continued SBM flexibility concerning auto re-enrollment.
Some states warn CMS of the potential penalties of proposed auto-renewal insurance policies. Colorado, for instance, factors out that even a product change that comes with a zero-dollar internet premium will carry a monetary danger when customers reconcile their superior premium subsidies at tax time. Oregon’s DOI and Marketplace means that transferring sure customers from bronze to silver will add pointless complexity for customers, enrollment assisters, and insurers, however asks that the coverage be expanded to CSR-eligible gold enrollees if finalized. Oregon additionally expresses concern over the potential future consideration of out-of-pocket prices in auto re-enrollments, describing doable penalties, equivalent to customers being moved away from plans with beneficiant pre-deductible protection to Health Savings Account (HSA)-eligible plans that impose a deductible on nearly all advantages, or customers transitioning away from plans with copayments and into plans with extra coinsurance.
Reducing Plan Choice Overload
Consumers searching for medical insurance on HealthCare.gov have extra choices than ever, however an excessive amount of of a very good factor can hinder a person’s skill to determine the very best plan for his or her well being and monetary wants. In an effort to simplify the patron procuring expertise, CMS has proposed two potential insurance policies to mitigate the dangers of this “choice overload.” One proposal limits the variety of non-standard plans an insurer collaborating on the Federally Facilitated Marketplace (FFM) or SBM utilizing the federal platform (SBM-FP) can supply alongside obligatory customary plan designs to 2 per metallic degree and product community sort. CMS estimates this cover would cut back common non-standard plan choices from practically 108 merchandise in plan yr 2022 to round 37 non-standard merchandise in plan yr 2024. The different proposal would require plans on the FFM and SBM-FP inside the similar “grouping,” by metallic degree, insurer, county, deductible integration sort, and product community sort, be “meaningfully different” from each other by having at the very least a $1,000 distinction in deductible. This coverage is projected to place much less downward stress on the variety of non-standard plans out there, lowering the plan yr 2022 baseline of roughly 108 non-standard merchandise to 53.2 such merchandise in 2024.
State feedback on these proposals fluctuate. Multiple feedback recommend that CMS permit extra state flexibility if imposing a cap on non-standard plans, notably in areas the place there aren’t presently an amazing variety of merchandise out there. Alaska’s DOI, for instance, highlights that solely two insurers take part within the federally facilitated market (FFM) within the state, and that some areas solely have one collaborating issuer, and requests that the state DOI have flexibility to determine when further plan choices serve client pursuits. Pennsylvania’s DOI, whereas insurers in that state’s SBM aren’t topic to the proposal, signifies the restrict on non-standard plans would supply a “helpful template” for SBMs to contemplate. Oregon’s DOI and Marketplace remark signifies that state officers “adamantly oppose[]” the proposed cap on non-standard plans, and as an alternative asks for improved performance on HealthCare.gov to simplify customers’ procuring expertise. The significant distinction customary proposal receives a barely hotter reception, though two state feedback request that the deductible distinction be lowered to $500. For its half, the NAIC urges flexibility for states if CMS implements both a non-standard plan restrict or a significant distinction customary, equivalent to letting states “opt out” of the plan restrict or allowing a alternative of various standards plans might fluctuate on, equivalent to HSA eligibility.
Network Adequacy
CMS has proposed new requirements for the inclusion of important neighborhood suppliers (ECP) in Marketplace plan networks for Plan Year 2024. These embrace establishing two further ECP classes, Mental Health Facilities and Substance Use Disorder Treatment Centers and requiring insurers on the FFM to contract with 35 p.c of Federally Qualified Health Centers (FQHC) and Family Planning Providers. The company additionally proposes to take away the choice for insurers to supply plans with out supplier networks. The NBPP additional alerts that CMS will transfer ahead with beforehand delayed appointment wait time requirements.
States have a combined response to those proposed insurance policies. The Oregon Marketplace and DOI and Pennsylvania’s DOI help the brand new ECP classes, and Oregon moreover approves of the upper threshold for FQHC and Family Planning Provider contracting. On wait time requirements, the NAIC notes concern about how insurers will reveal compliance, citing points with knowledge and regulators’ skill to guage the insurer attestations that CMS will depend on for this side of community adequacy evaluate. Accordingly, NAIC requests that CMS additional develop the coverage previous to “robust enforcement.” Pennsylvania’s DOI, nevertheless, applauds the wait time requirements for the FFM and SBM-FPs, and asks CMS to use a “minimum floor” throughout Marketplaces, together with SBMs. Meanwhile, the Ohio DOI devotes its whole remark letter to opposing the top of non-network plans on the Marketplaces, asserting it should “stifle innovation.”
Other Issues
States in our pattern convey up numerous different points of their feedback. In explicit, each Marketplace opposes or has considerations in regards to the proposed improper fee reporting program. Most states additionally touch upon proposed particular enrollment interval (SEP) modifications, usually supporting CMS’s proposals to extend entry to mid-year enrollment alternatives and continued flexibility for SBMs concerning whether or not to implement sure federal market SEP insurance policies. States additionally present suggestions on the proposal to take away a prohibition on enrollment assisters going door-to-door to succeed in customers with a restricted skill to journey, with most feedback that debate the coverage expressing help. Finally, whereas most states in our pattern don’t pay a federal person charge, a number of feedback talk about the proposed modifications to the person charge. NAIC approves of the lowered person charge charges. Oregon, which is topic to an SBM-FP person charge, and Colorado, which isn’t, each request further transparency concerning person charges and the way they’re allotted.
A Note on Our Methodology
This weblog is meant to supply a abstract of feedback submitted by SBMs and state DOIs. This just isn’t supposed to be a complete report of all feedback on each ingredient within the Notice of Benefit and Payment Parameters proposed rule, nor does it seize each element of the reviewed feedback. For extra stakeholder feedback, go to https://www.regulations.gov/.