On April 28, 2022, the United States Centers for Medicare and Medicaid Services (CMS) and Department of Health and Human Services (HHS) released the 2023 Notice of Benefit and Payment Parameters Final Rule. In the Final Rule, the agencies finalize standards for issuers and Marketplaces, as well as requirements for agents, brokers, web-brokers, and issuers that help consumers with enrollment through Marketplaces that use the federal platform. The Rule aims to strengthen the coverage offered by qualified health plans (QHPs) on the federal marketplace.
Standardized Plan Options
In the Final Rule, CMS finalized changes to require issuers in the Federally-facilitated Marketplace (FFMs) and State-based Marketplaces on the Federal Platform (SBM-FPs) to offer standardized plan options at every product network type, at every metal level, and throughout every service area that they offer non-standardized options in PY 2023 and beyond.
Under the new rules, if an issuer offers a non-standardized gold HMO QHP in a particular service area, that issuer must also offer a standardized gold HMO QHP throughout that same service area.
CMS finalized two sets of standardized plan options at each of the bronze, expanded bronze, silver, silver cost-sharing reduction (CSR) variations, gold, and platinum metal levels of coverage, with each set tailored to the unique cost-sharing laws in different sets of states.
FFM and SBM-FP User Fees
For the 2023 benefit year, CMS finalizes an FFM user fee rate of 2.75% of premium and a SBM-FP user fee rate of 2.25% of premium.
CMS also finalized two of the three proposed model specification changes to the risk adjustment models, improving risk prediction for the lowest and highest risk enrollees. Beginning with the 2023 benefit year, CMS will remove the current severity illness factors from the adult models, add an interacted hierarchical condition category (HCC) count model specification to the adult and child models, and replace the current enrollment duration factors in the adult models with HCC-contingent enrollment duration factors to improve prediction for partial-year enrollees. CMS did not finalize the proposed addition of a two-stage weighted model specification for the adult and child models.
Advancing Health Equity
CMS refined its Essential Health Benefits (EHB) nondiscrimination policy to ensure that benefit designs are based on clinical evidence, especially benefit limitations and plan coverage requirements for EHB. CMS provided some examples of presumptive discriminatory plan designs, including discrimination based on age and health conditions. CMS rules already provide that an issuer does not provide EHB if its benefit design, or the implementation of its benefit design, discriminate based on an individual’s age, expected length of life, present or predicted disability, degree of medical dependency, quality of life, or other health conditions.
PhRMA Statement
Stephen J. Ubl, president and CEO of PhRMA, released a statement, saying “Today’s Biden Administration decision on standardized benefit designs is a win for patients by ensuring insurance works like it should. This will make a real difference in lowering costs at the pharmacy for patients who get their insurance from HealthCare.gov. These types of reforms help build a better health care system for everyone.”