7 Key Changes to ACA Enrollment, Plan Selection in 2024 Proposed Rule

The Biden administration has released its 2024 Notice of Benefit and Payment Parameters Proposed Rule which focused on streamlining Affordable Care Act health plan selection, simplifying Affordable Care Act marketplace enrollment, and increasing access to care.

“The Biden-Harris Administration has taken historic action to expand access to health care, and the Affordable Care Act Marketplace provides millions of Americans vital coverage,” Department of Health and Human Services (HHS) Secretary Xavier Becerra said in the press release.

First, CMS proposed tweaking standardized plans: their benefits and the number of existing Affordable Care Act standardized plans.

CMS suggested capping the number of standardized plans that qualified health plan issuers can offer. Under this policy, plan issuers could offer two standardized plans per product network type and metal level in a service area.

“Under this proposed requirement, an issuer would, for example, be limited to offering through a Marketplace two gold health maintenance organization (HMO) and two gold preferred provider organization (PPO) non-standardized plan options in any service area in PY2024 or any subsequent PY,” the fact sheet stated.

The agency would eradicate standardized plans at the non-expanded bronze metal level.

Standardized plans would be required to cover generic drugs in the generic cost-sharing tier or specialty drug tier given certain requirements. They also have to put brand-name drugs in the preferred, non-preferred, or specialty tiers.

Second, CMS recommended loosening restrictions around automatic re-enrollment hierarchies.

Under the new automatic re-enrollment hierarchy, eligible enrollees would be automatically enrolled in silver-level qualified health plans with cost-sharing reductions where they have a lower or equal premium. Under the traditional hierarchy, these enrollees would be re-enrolled in bronze-level qualifying health plans with no cost-sharing reductions.

Additionally, eligible individuals enrolled in qualified health plans that are no longer available can be re-enrolled automatically to plans with similar networks.

Third, the agency offered marketplaces flexibility around when and how consumers can sign up for coverage on the Affordable Care Act marketplace.

CMS proposed offering states more special enrollment period options for individuals losing their Medicaid or Children’s Health Insurance Program (CHIP) coverage. Under these changes, the special enrollment period would start 60 days before coverage loss or extend until 90 days after coverage loss.

The agency also introduced the idea of allowing Navigators and assisters to conduct door-to-door enrollment instead of door-to-door outreach.

“The prohibition on door-to-door enrollment during the first contact burdens the consumer and assisters and creates access barriers for consumers to receive timely enrollment assistance,” the fact sheet argued.

Fourth, CMS suggested changes to the user fees for both the federally facilitated marketplace (FFM) and the state-based marketplaces on the federal platform (SBM-FP) in order to decrease premium costs.

Both fees would experience a 0.25 percent drop in the user fee, which is presented as a percent of the health plan’s premium. The new user fee rate for the FFM qualified health plans would be 2.5 percent of the plan premiums in 2024. The qualified health plans of SBM-FPs would face a user fee that is 2.0 percent of plan premiums.

Fifth, the agency would make changes to the HHS risk adjustment program and risk adjustment data validation.

The only change to the risk adjustment model for 2024 is relevant for the adult models’ age-sex coefficients. The agency is using enrollee-level EDGE data for the model’s recalibration but in 2024 it would not use EDGE data for 2020 enrollee-level data. CMS proposed collecting data from a qualified small employer health reimbursement arrangement (QSEHRA) indicator, plan ID, and rating area data.

The agency would keep the hepatitis C drug market pricing adjustment in the plan liability market pricing adjustment. Also, CMS would implement a user fee of $0.21 per member per month.

CMS requested industry stakeholders’ input regarding introducing a payment hierarchical condition category (HCC) for gender dysphoria.

Sixth, CMS also suggested a new program that would help state marketplaces be prepared for advance payment of the premium tax credit improper payment assessments.

The agency tests state marketplaces’ advance premium tax credit measurements. The proposed rule would initiate a program that prepares states for this testing process starting in calendar years 2024 through 2025.

Lastly, CMS would instate new rules around agents, brokers, and web-brokers.

Under the proposed rule, HHS would have more time to review evidence that these entities may submit when suspended or requesting reconsideration of their termination. Traditionally, HHS has 30 days to review the materials for suspensions and terminations. But under the new rule, HHS would have 45 days for suspensions and 60 days for terminations.

CMS suggested that agents, brokers, and web-brokers should collect and retain evidence that enrollees’ eligibility information has been reviewed and confirmed before enrollees submitted their applications. They would also have to keep receipts of consent from enrollees. These data would be preserved for at least 10 years.

“We know that access to affordable health care is a concern across the nation. During the first several weeks of Affordable Care Act Marketplace Open Enrollment, we have already seen 5.5 million people select a Marketplace health plan, an 18% increase compared to last year,” CMS Administrator Chiquita Brooks-LaSure added in the press release.

“Continuing to propose policies that help make it easier for consumers to choose and maintain the health coverage that best fits their needs is vital. If finalized, this proposed rule does just that.”

Early Affordable Care Act enrollment trends for the 2023 plan year were on track to outpace 2022 enrollment, which was a record-breaking enrollment period. Signups in November 2022 for plan year 2023 were 40 percent higher than the enrollment numbers in November 2021 for plan year 2022.