On April 17, 2023, the Centers for Medicare & Medicaid Services (“CMS”) released the U.S. Department of Health and Human Services (“HHS”) Notice of Benefit and Payment Parameters for 2024 Final Rule (the “Notice”) that includes standards for issuers and Marketplaces, and requirements for agents, brokers, web-brokers and others. The Final Rule aims to enhance affordability, accessibility, and choice for consumers, strengthen consumer protections, improve program integrity, and support state innovation in implementing the Affordable Care Act.
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CMS now requires all individual market qualified health plans (“QHPs”), including stand-alone dental plans (“SADPs”) and all Small Business Health Option Program plans across all Marketplace-types, to use a network of providers that comply with the standards set out in the network adequacy and essential community provider regulations. Further, the new rules remove the previous exception to the network adequacy standards that allowed plans not using a network provider to avoid compliance with said standards, while creating a new limited exception to the requirement for SADP issuers selling plans in areas where it is “prohibitively difficult” for the issuer to establish a network of dental providers.
As part of its drive to simplify consumer choices regarding health plans, CMS has implemented a number of changes aimed at increasing efficiency and reducing consumer confusion. First, CMS has removed the standardized plan option for the “non-expanded” bronze metal level. As such, beginning in the plan year 2024, issuers who offer QHPs through Federally Facilitated Marketplaces and State-based Marketplaces on the federal platform must offer standardized QHP options designed by CMS at every product network type, at every metal level except the non-expanded bronze metal level, and in every service area for which that issuer offers non-standardized QHPs.
Additionally, CMS has decreased the amount of non-standardized plan options that issuers who offer QHPs can offer through Marketplaces on the Federal platform: beginning in plan year 2024, the number of non-standardized plan options will be limited to four non-standardized plan options per product network type, metal level (excluding catastrophic plans) and inclusion of dental and/or vision benefit coverage, in any service area. Beginning plan year 2025, the four-option limit will drop to two. CMS’ rationale for this change is to cut down on the large number of plans being offered, and in doing so help to both alleviate the risk of choosing ineffective health plans and to avoid plan choice overload by consumers. However, CMS will permit flexibility for plans that provide a certain amount of additional dental and/or vision benefit coverage.
CMS has also implemented a new rule, beginning January 1, 2024, to prevent consumers from losing Medicaid or Children’s Health Insurance Program (“CHIP”) coverage which is also considered minimum essential coverage. The new rule requires that consumers be given 90 days after the loss of Medicaid or CHIP coverage to select a plan for Marketplace coverage in a Special Enrollment Period. The Special Enrollment Period now aligns with the Medicaid/CHIP reconsideration period, which is also 90 days and allows consumers to have their coverage requests reconsidered without needing to submit new applications. State-based Marketplaces will have the option to give consumers who are losing Medicaid or CHIP coverage more time to select a QHP, and will be able to implement this new rule before January 1, 2024 if they so desire.
Furthermore, CMS also finalized a number of administrative changes in the Notice. For the 2024 plan year, CMS has implemented a user fee rate of 2.2% of premium for QHPs sold on the Federally Facilitated Marketplaces and a user fee rate of 1.8% of premium for QHPs sold on the State-based Marketplaces on the Federal platform. These fee rates have been lowered from the previous rates and should help to lower premiums for consumers.
Finally, CMS imposed two new requirements regarding the activities of agents, brokers and web-brokers. Agents, brokers, or web-brokers are now required to document that eligibility application information for consumers has been reviewed by and confirmed to be accurate by the consumer or a representative. They must also document the consent of a consumer or a representative to receiving assistance prior to providing such assistance. Both items of documentation must be retained for at least 10 years in order to assist with audit and enforcement activities, and must be produced upon request.