HHS Finalizes Notice of Benefit and Payment Parameters for 2024

What CMS finalized

The administration underscored its goal of improving health equity by requiring qualified health plans on the individual health insurance marketplace and other specific categories of plans to align with network adequacy standards. Previously there were exceptions that left room for coverage and care disparities.

The rule finalized mental health facilities and substance use disorder treatment centers as essential community provider (ECP) categories and expanded the Other ECP category to include rural healthcare providers in order to improve health equity.

Qualified health plans will have until plan year 2025 to comply with appointment wait time standards. CMS will release the appointment wait time standard guidelines at a later date.

The final rule eliminated the non-expanded bronze metal level standardized plan option. Any issuers that offer qualified health plans on the federally facilitated marketplace or on state-based marketplaces on the federal platform will have to eliminate this option from their offerings.

Additionally, on the federal platform, qualified health plan issuers will now be limited to four non-standardized plans offerings per metal level, network type, and dental and/or vision coverage inclusion. There will be some exceptions for plans with extra dental and/or vision coverage. State-based marketplace offerings, stand-alone dental plans (SADPs), and all Small Business Health Option Program (SHOP) plans will not have to comply.

Marketplaces can change their automatic re-enrollment hierarchies to re-enroll individuals who are eligible for cost-sharing reductions in silver-level qualified health plans. In these silver-level plans, consumers will keep their provider networks and their premium with the advanced premium tax credits. Marketplaces can begin to “crosswalk” their enrollees in plan year 2024.

The agency will assess plan names and variant marketing names to prevent misleading plan names.

Through a new special enrollment period, Marketplaces will be able to offer consumers up to 90 days after their Medicaid or Children’s Health Insurance Program (CHIP) coverage loss to choose a Marketplace plan. State-based marketplaces can offer this option as soon as the rule goes into effect.

Additionally, consumers will be able to attest to future minimum essential coverage loss and apply for Affordable Care Act marketplace coverage in advance. If they apply before the first day of the month that they will lose coverage, they can have Marketplace coverage starting the first day of the month that they anticipate losing coverage.

Starting on the day that the final rule goes into effect, a consumer must fail to file a federal income tax return and reconcile past APTCs two years in a row before Affordable Care Act marketplace plans can deny them eligibility.

The user fee rate for federally facilitated marketplaces will be 2.2 percent of the qualified health plan premium in 2024 and the user fee rate for state-based marketplaces on the federal platform will be 1.8 percent of the qualified health plan premium.

Risk adjustment for the 2024 benefit year will be based on 2018, 2019 and 2020 enrollee-level EDGE data. CMS will extract a Qualified Small Employer Health Reimbursement Arrangement (QSEHRA) indicator from plans’ EDGE data starting in benefit year 2023.

“Beginning with the 2021 benefit year of HHS-RADV, CMS finalizes no longer exempting exiting issuers from adjustments to risk scores and risk adjustment transfers when they are a negative error rate outlier in the applicable benefit year’s HHS-RADV results,” the agency announced.

State marketplaces must participate in the Improper Payment Pre-Testing and Assessment (IPPTA) program.

CMS gave HHS 45 days to assess evidence from agents, brokers, and web-brokers regarding marketplace suspension, instead of 30 days under previous regulations. Agents, brokers, and web-brokers must also prove to CMS that consumers have affirmed the eligibility application information. These entities will be required to save evidence that the consumer consented to receive the entities’ support for at least a decade.

What CMS did not finalize

CMS will not finalize certain parts of the proposed rule. Specifically, the agency had included certain rules for standardized plan option issuers regarding generic and brand-name drug cost-sharing tiers that were excluded from the final rule.

The agency chose not to finalize the proposed meaningful difference standard. The meaningful difference standard introduced a way of grouping plans to assess their deductibles and determine whether the plans were sufficiently distinct. In the final rule, the agency chose to limit the number of non-standardized plan options instead of employing the meaningful difference standard.