CMS proposes changes to ACA network adequacy, standardized plans rules

The Centers for Medicare and Medicaid Services aims to reduce the number of non-standard policies offered on the health insurance exchanges while boosting the availability of providers in carriers’ networks, according to a draft regulation released Monday.

The proposed rule would require participating health insurers to comply with state and federal network adequacy standards and would review their contracts with substance use disorder treatment centers and mental health facilities to ensure there are providers available to members. CMS would require insurers to promote their coverage of substance use disorder and mental treatments by organizing providers into separate categories and instructing insurers to include at least 35% of the providers in any given market in their networks.

The agency also aims to increase the availability of standardized plans and limit the number of non-standardized health plans sold on the exchanges. CMS would limit the number of number of non-standardized plans carriers can offer for every network type at each metal level to two. The average number of plans available to consumers ballooned from 27 in 2019 to 131 for 2023, according to a CMS fact sheet.

For example, exchange insurers could sell just two gold, non-standard HMOs and two gold, non-standard PPOs per service area. The agency is considering requiring insurers to group plans by county, metal level, product type and more, as a way to simplify comparison shopping. This requirement would only apply to insurers selling in states that use the federal marketplace platform.

The regulation anticipates the Medicaid and Children’s Health Insurance Program eligibility redetermination process that will kick off when the federal government’s COVID-19 public health emergency lapses. CMS proposes establishing special enrollment periods for people who lose Medicaid or CHIP benefits because their income rose during the pandemic, when states were not permitted to trim their benefit roles in exchange for federal COVID-19 relief. An estimated 18 million low-income adults and children could lose coverage when the emergency designation expires, according to by the Robert Wood Johnson Foundation. The public health emergency is currently scheduled to end in April.

The 2024 Notice of Benefit and Payment Parameters proposed rule also includes provisions to:

• Decrease the user fees insurers must pay by 0.25% on both the federal and state marketplaces. Carriers would pay 2.5% premiums for plans sold on the federal marketplaces, and 2% premiums for sold on state marketplaces.
• Allow exchange navigators to visit individuals’ homes and help them sign up for health insurance on their initial visits. Navigators are currently allowed to visit customers’ homes, but are not permitted to enroll them the first time they meet.
• Update the risk-adjustment data that plans must submit for 2024, and charge insurers a per-member fee for calculating what they owe or are owed under the federal program. The risk-adjustment program requires plans that insure healthier customers to pay into a pool for insurers with sicker and costlier policyholders.
• Modify the automatic enrollment process for low-income consumers to direct those who qualify for cost-sharing reductions to silver plans with similar provider networks to their current bronze plans.
• Review plan names to make sure that they accurately describe the products. CMS would require plans to submit their plans’ marketing names for federal or state approval.
• Require brokers to confirm with customers their income and other personal information before submitting applications. CMS aims to extend the amount of time the Health and Human Services Department has to act on consumer complaints against brokers.