CMS, HHS Finalize 2023 Notice of Benefits, Payment Parameters

CMS and the Department of Health and Human Services (HHS) released the 2023 Notice of Benefits and Payment Parameters Final Rule, which includes standardized plan options, changes to network adequacy reviews, refinements to the Affordable Care Act’s essential health benefits nondiscrimination policy, and other changes.

“The recent Open Enrollment Period demonstrated the demand for high-quality, affordable health coverage. These steps increase the value of health care coverage on HealthCare.Gov and further strengthen the health insurance Marketplace,” CMS Administrator Chiquita Brooks-LaSure said in a press release.

The final rule solidified the federally-facilitated marketplace (FFM) user fee rate at 2.75 percent of the premium and the state-based marketplace-federal platform (SBM-FP) will be 2.25 percent of the premium. The risk adjustment user fee will be $0.22 per member per month.

CMS finalized that FFM and SBM-FPs have to offer standardized plan options, one for every metal level. These plans must be available in every service area in which non-standardized plans are offered. The agency established two sets of standardized plan options for each metal level.

To support network adequacy, CMS finalized the prospective network adequacy reviews. The reviews will focus on time and distance as well as appointment waiting times starting in plan year 2024 and whether providers offer telehealth options.

“The Affordable Care Act has successfully expanded coverage and provided hundreds of health plans for consumers to choose from,” said HHS Secretary Xavier Becerra. 

“By including new standardized plan options on HealthCare.gov, we are making it even easier for consumers to compare quality and value across health care plans. The Biden-Harris Administration will continue to ensure coverage is more accessible to every American by building a more competitive, transparent, and affordable health care market.”

Administrator Brooks-LaSure agreed.

“This policy will make it easier for people to choose the best plan that meets their needs by standardizing plan options, like maximum out-of-pocket limitations, deductibles, and cost-sharing features,” Administrator Brooks-LaSure added.

CMS finalized two out of three changes the risk adjustment models in the proposed rule. The two finalized changes were: incorporating an interacted hierarchical condition category (HCC) count model specification for both the adult and child risk adjustment models and using HCC-contingent enrollment duration factors instead of current enrollment duration factors.

The two-stage weighted model was not finalized.

CMS finalized certain data collection changes as well, such as adding five data points to the EDGE servers: ethnicity, race, an individual coverage health reimbursement arrangement (ICHRA) indicator, a subsidy indicator, and ZIP code.

CMS also finalized changes to the HHS Risk Adjustment Data Validation.

State-based marketplaces will not have to prorate premium or advance premium tax credits, but those using the federal platform will have to be prorated.

When CMS released the proposed rule, payers expressed concerns about the risk adjustment process, specifically the five new enrollee data points, as well as the standardization of Affordable Care Act plans.