Proposed 2024 Fee Rule, Half 1: Insurance coverage Market Reforms And Shopper Help

On December 12, 2022, the U.S. Division of Well being & Human Companies (HHS) launched a proposed rule to refine and replace Plan 12 months 2024 requirements for well being insurers and Marketplaces below the Reasonably priced Care Act (ACA). Along with the proposed 2024 Notice of Benefit & Payment Parameters (NBPP) the company additionally launched a Fact Sheet, the 2024 Draft Letter to Issuers, the 2024 Actuarial Worth Calculator and Methodologyguidance on fee parameters, and a response to Alabama’s request for threat adjustment flexibility. Feedback on the proposals should be submitted by January 30, 2023.

The proposed rule builds on just lately carried out necessities for standardized plans, community adequacy, and truthful advertising requirements. It continues this administration’s efforts to decrease administrative limitations to enrollment and strengthen shopper help. It additionally consists of modifications to threat adjustment, Advance Premium Tax Credit score (APTC) coverage, market transitions, person charges, and different market requirements. All through the proposed rule and related supplies, the administration emphasizes its curiosity in enhancing well being fairness and lowering disparities in well being protection and entry.

On this first of three Forefront articles on the 2024 NBPP, we give attention to proposed market reforms and shopper help enhancements. The second and third articles give attention to proposed modifications to the chance adjustment program, market operational requirements, and APTC insurance policies.

Standardized Plan Choices

HHS is proposing “minor” updates to the standardized plan choices supplied throughout open enrollment for plan yr 2023. Readers will recall that the Obama administration had launched standardized plans (known as “Easy Selection” plans) for the federally facilitated marketplaces (FFM) starting in 2017, however these had been discontinued by the Trump administration within the 2019 NBPP. The Biden administration re-introduced standardized plans in its 2023 NBPP. Beneath that rule, issuers within the FFM and state-based marketplaces that use the federal platform (SBM-FP) are required to supply plans with standardized advantages designed by HHS at each product community kind, at each steel degree, and all through each service space through which they provide plans within the particular person market. The relevant steel ranges embody each expanded and non-expanded Bronze plans (“expanded” Bronze plans cowl not less than one non-preventive service pre-deductible or meet the IRS’ definition of a high-deductible well being plan and are permitted to have an actuarial worth of as much as 5 factors above the 60 % customary), Silver (for traditional Silver and for every of the three CSR variants), Gold, and Platinum plans.

HHS didn’t prolong the requirement to supply standardized plans to issuers in state-based market (SBM) states, partially as a result of eight of those states already require their very own variations of standardized plans. HHS additionally exempted issuers within the state of Oregon, an SBM-FP, as a result of that state additionally requires particular person market issuers to supply standardized plans. The 2023 rule permits issuers to proceed to supply as many non-standardized plan choices as they select.

Within the 2023 NBPP, HHS created two totally different units of standardized plan designs, one set for states with their very own cost-sharing necessities for particular person market issuers complying with the legal guidelines in these states, and a second set for states with out such necessities. HHS additionally labored to design the standardized plans to be as related as doable to the preferred plan designs in every state.

HHS calls the brand new standardized plans “Simple Pricing” plans and customers can apply filters on to view and examine solely standardized plans. Net-brokers offering Direct Enrollment (DE) and Enhanced Direct Enrollment (EDE) should additionally supply and differentially show the Simple Pricing plans in keeping with’s show, until HHS approves a request for a deviation.

For plan yr 2024, HHS proposes to keep up the Simple Pricing plans on, with some modest modifications. First, HHS would not require issuers to supply a standardized plan on the non-expanded Bronze steel degree. The company discovered it infeasible to design a non-expanded Bronze plan that features any pre-deductible protection that meets the actuarial worth goal inside the permissible de minimis vary. In addition they observe that the majority FFM issuers selected to not supply non-expanded Bronze plans, providing solely expanded Bronze as a substitute.

HHS intends to proceed the usage of 4 prescription drug tiers in its standardized plans, particularly: generic medicine, most well-liked model medicine, non-preferred model medicine, and specialty medicine. The company believes limiting the formulary to 4 tiers promotes comprehensible drug protection and facilitates customers’ capability to check amongst plan choices. Nevertheless, they sign openness to increasing the variety of formulary tiers in future years and invite touch upon the suitable variety of drug tiers in standardized plans.

HHS has obtained stories that some issuers are usually not inserting sure medicine on the applicable cost-sharing tiers. For instance, some issuers are together with generic medicine in the popular or non-preferred cost-sharing tiers. Consequently, the company proposes to require that issuers place all coated medicine within the applicable cost-sharing tier until there’s an “applicable and non-discriminatory foundation” for putting the drug within the specialty tier.

Limits For Non-Standardized Plan Choices

HHS is proposing to restrict the variety of non-standardized plans that issuers can supply via the FFM or SBM-FPs to 2 per product community kind and steel degree, per service space. For instance, below this rule issuers could be restricted to providing two gold HMO and two gold PPO non-standardized plans in any service space, starting in plan yr 2024. These limits wouldn’t prolong to plans supplied via SBMs or the SHOP (Small Enterprise Well being Choices Program) marketplaces, nor would they apply to stand-alone dental plans (SADPs).

On account of this proposed restrict, HHS estimates that the weighted common variety of non-standardized plan choices obtainable to customers could be diminished from 107.8 in plan yr 2022 to 37.2 in plan yr 2024. This quantity doesn’t embody the standardized plan choices. The company additional estimates that roughly 2.72 million present enrollees would have their plans discontinued because of these new limits, requiring issuers to crosswalk them into a brand new plan for 2024.

In its rulemaking for plan yr 2023, HHS raised issues and solicited feedback about “plan alternative overload” for market customers, pointing to quite a few research which have discovered that too many well being plan selections can result in poor enrollment selections. In response, many commenters agreed that too many plan choices can lead to shopper confusion and frustration, with many arguing that the variety of plan selections now supplied on the marketplaces has elevated past some extent that’s productive for customers. Certainly, the variety of plans obtainable to the common market shopper has grown from 25.9 in 2019 to 113.6 in 2023.

On the identical time, HHS notes that it has carried out quite a few enhancements to the selection structure on to assist customers higher perceive and examine their plan choices. Nevertheless, the company believes that enhancing {the marketplace}’s alternative structure is important however not adequate, by itself, to scale back the selection overload that buyers at present face.

An Different Technique

One other method to doubtlessly scale back shopper alternative overload is to impose a “significant distinction” requirement on issuers’ plan choices. The Obama administration had launched such an ordinary in 2015, however this was reversed by the Trump administration in 2019. As initially outlined, a plan was thought-about “meaningfully totally different” from one other plan supplied by the identical issuer if an affordable shopper would have the ability to establish materials variations between plan traits akin to (1) price sharing or out-of-pocket most; (2) supplier networks; (3) coated advantages; (4) plan kind; (5) HSA eligibility; or (6) self-only, non-self-only, or youngster solely choices.

HHS is proposing, as a substitute for limiting the variety of issuers’ plan choices, to reinstate the significant distinction customary. Nevertheless, they observe that many commenters and stakeholders have argued that the unique significant distinction customary was not rigorous sufficient to meaningfully scale back duplicative plan designs. Consequently, HHS would replace the significant distinction customary. The company proposes that it might group plans by issuer ID, county, steel degree, product community kind, and deductible integration kind, after which consider whether or not plans inside every group are meaningfully totally different, primarily based on variations in deductible quantities. Deductibles must differ by greater than $1,000 to fulfill the brand new customary.

HHS is in search of touch upon its two proposed approaches to lowering shopper alternative overload: (1) limiting the variety of plan choices or (2) reinstating a significant distinction customary that’s extra rigorous than the one utilized in plan years 2015-2018.

Price And Profit Data For QHPs

A Uniform Age-Ranking And Eligibility Methodology For SADPs

HHS proposes to require that SADP issuers set their premium charges and decide plan eligibility primarily based on an enrollee’s age on the time the coverage issued or renewed, starting in 2024. Thus far, SADP issuers have had flexibility to determine how an applicant or an enrollee’s age is decided. The company notes that almost all of SADP issuers use a person’s age upon coverage efficient date to find out eligibility and charges and argues that that is additionally probably the most simple methodology for customers to know. The company asserts that permitting SADPs continued flexibility to price by different strategies creates an excessive amount of complexity for each the marketplaces and customers. HHS would prolong this requirement to SADP issuers in FFM, SBM-FP, and SBM states.

Assured Charges For SADPs

Since 2014, HHS has allowed SADP issuers to supply both assured or estimated charges. Beneath a assured price, the SADP issuer should decide to charging the authorised price, whereas below estimated charges, the enrollee should contact the issuer to search out out their remaining price. HHS notes that this flexibility was solely made obtainable to SADP issuers within the early years of the marketplaces due to operational constraints. The company has now improved the required templates and types, enabling extra standardized score guidelines for dental plans. HHS thus proposes to require SADP issuers, as a situation of market certification, to submit solely assured charges. The company argues that requiring assured charges would assist forestall inaccurate determinations of APTCs for the pediatric dental portion of a shopper’s premium, which might primarily assist lower-income customers who qualify for APTCs. The company additionally notes that though SADP issuers at present have the pliability to submit estimated charges, the overwhelming majority select to submit assured charges. HHS proposes to increase this requirement to SADP issuers in FFM, SBM-FP, and SBM states.

Plan And Plan Variation Advertising and marketing Identify Necessities For Certified Well being Plans

In recent times, HHS has obtained complaints from customers in quite a few states about deceptive or misleading plan advertising names. The company, alongside state insurance coverage regulators, investigated and located that many plan names that embody cost-sharing or different profit particulars usually are incorrect or deceptive, primarily based on data submitted in plan paperwork. Examples of such deceptive plan names embody cost-sharing quantity limits that don’t point out that such limits are solely obtainable for a sure prescription drug or supplier community tier, greenback quantities that don’t specify what they check with, and the usage of “HSA” within the plan title when the plan doesn’t enable the enrollee to arrange an HSA.

HHS proposes to require that advertising names for market certified well being plans (QHP) embody appropriate data and don’t embody content material that’s deceptive. To implement this, HHS would assessment plan advertising names throughout the annual QHP certification course of, in collaboration with state regulators in FFM states. The company seeks touch upon this proposal. Specifically, they ask whether or not the company ought to set up a required format for plan advertising names, with specified components, to be used by all QHPs.

Community Adequacy

Plans That Do Not Use A Supplier Community

HHS proposes to require all market plans, SADPs, and SHOP plans to make use of a community of suppliers that adjust to its community adequacy and important neighborhood supplier (ECP) necessities. If finalized, this might remove the exemption that applies to plans that don’t keep a supplier community. The company notes that, since 2016, just one FFM issuer has supplied a plan that doesn’t use a supplier community.

The ACA requires that market plans guarantee a “adequate alternative” of suppliers and supply data to enrollees in regards to the availability of in-network and out-of-network suppliers. The statute additionally requires that plans “embody inside medical insurance plan networks these important neighborhood suppliers, the place obtainable, that serve predominantly low-income, medically-underserved people.” HHS argues that plans can’t adjust to these necessities, and the company can’t successfully implement compliance, if the plan doesn’t use a supplier community. The company additionally believes that requiring use of a supplier community would higher shield customers from potential harms, akin to lack of supplier entry, that may happen when a QHP doesn’t use a community. HHS seeks touch upon this proposal, together with the requirement to increase it to SADP issuers.

Appointment Wait Time Requirements

Starting in 2023, issuers providing plans on the FFM and SBM-FP should be certain that their enrollees can acquire supplier companies inside a most time or distance from their houses. In its 2023 NBPP, HHS additionally required QHP issuers to satisfy minimal appointment wait time requirements however delayed implementation of that requirement to plan yr 2024, citing issues in regards to the compliance burden on issuers. Right here, HHS places its FFM and SBM-FP issuers on discover that they have to start working with their community suppliers to gather the info wanted to evaluate appointment wait occasions and decide if their supplier community meets the wait time requirements detailed within the 2023 Letter to Issuers. HHS will start reviewing issuer attestations of compliance for plan yr 2024.

Important Group Suppliers

In its fee discover for 2023, HHS set a brand new bar for the inclusion of important neighborhood suppliers (ECPs) in market plan networks. For plan yr 2023 and past, issuers within the FFM should have 35 % of obtainable ECPs taking part of their plan networks, up from the 20 % threshold required in previous years. QHPs should supply a contract in good religion to not less than one supplier in every ECP class in every county within the plan’s service space. At the moment, there are six classes of ECP suppliers:

  • Federally Certified Well being Facilities (FQHC)
  • Ryan White Program Suppliers
  • Household Planning Suppliers
  • Indian Well being Care Suppliers
  • Inpatient Hospitals
  • Different ECP Suppliers (outlined to incorporate Substance Use Dysfunction Therapy Facilities, Group Psychological Well being Facilities, Rural Well being Clinics, Black Lung Clinics, Hemophilia Therapy Facilities, Sexually Transmitted Illness Clinics, and Tuberculosis Clinics).

Within the 2024 NBPP, HHS is proposing two modifications to its ECP requirements. First, it might create two new and distinct ECP classes: Psychological Well being Services and Substance Use Dysfunction (SUD) Therapy Facilities. These suppliers would thus be faraway from the “Different ECP Suppliers” class. Creating these two new classes would require issuers to aim to contract with not less than one SUD Therapy Heart and not less than one Psychological Well being Facility. HHS would additionally add Rural Emergency Hospitals as a supplier kind within the “Different ECP Suppliers” class.

Second, HHS is proposing to require QHPs to contract with not less than 35 % of obtainable FQHCs and not less than 35 % of obtainable Household Planning Suppliers that qualify as ECPs inside the plan’s service space. This is able to be along with the present requirement that plans have not less than 35% of all obtainable ECPs inside their service space, in-network. For 2024, HHS is specializing in FQHCs and Household Planning Suppliers as a result of these are the biggest classes of suppliers (representing roughly 62% of all amenities on the ECP record). Nevertheless, the company is contemplating including a specified minimal threshold to different ECP classes sooner or later. HHS doesn’t consider this requirement could be tough for QHP issuers to satisfy, noting that of 2023 QHP issuers, 75% would already meet or exceed the 35% threshold for FQHCs and 61% would meet the brink for Household Planning suppliers.

Prohibiting Mid-12 months Terminations For Dependent Youngsters Who Attain Most Age

The ACA requires group well being plans and insurance coverage issuers that provide protection to dependent kids to permit these kids to remain on their mother and father’ plan till age 26. Operationally, requires issuers that cowl dependent kids to keep up that protection till the tip of the plan yr through which they flip 26. On this proposed rule, HHS would codify this requirement in regulation to offer extra readability for taking part issuers and scale back enrollee uncertainty about their protection. This requirement would apply to plans supplied via the FFM and SBM-FPs. SBMs may implement the same rule at their choice. The company notes that, with respect to households that obtain APTCs, {the marketplace} makes eligibility determinations for the whole plan yr. {The marketplace} will proceed to pay APTCs to the issuer, together with the portion attributable to a dependent youngster, via the tip of the plan yr through which the dependent youngster turns 26. If in any other case eligible, the member of the family that has turned 26 will likely be re-enrolled right into a separate coverage starting January 1 of the next plan yr, with any APTCs for which they’re eligible.

Establishing A Timeliness Commonplace For Notices Of Fee Delinquency

When a plan enrollee turns into delinquent in making premium funds, HHS requires insurers to ship a discover to the enrollee so that they have a possibility to pay unpaid premiums and keep away from a termination of their protection. In conducting oversight of issuers, the company discovered that some had been delaying sending these notices, in excessive instances stopping the enrollee from correcting their delinquency. HHS is thus proposing establishing a timeliness customary for these notices and asks for touch upon what an affordable timeframe could be.

Requirements For Navigators And Different Shopper Assisters

Permitting Door-To-Door Help

Federal guidelines at present prohibit Navigators, licensed utility counselors, and non-Navigator help suppliers (“Assisters”) from going door-to-door or utilizing unsolicited means to offer enrollment help to customers. HHS is proposing to repeal that prohibition. The company notes that it has established safeguards to make sure that Assisters are sustaining the privateness and safety of customers’ data. It additionally argues that prohibiting Assisters from going door-to-door creates limitations for customers who should make appointments to acquire enrollment assist and imposes undue burdens on people whose journey is proscribed by lack of mobility or inexpensive transportation, or who’re immunocompromised.

Guidelines For Brokers And Brokers

The proposed rule would set up new necessities for brokers, brokers, and web-brokers that help customers with FFM and SBM-FP enrollments. Present federal guidelines allow HHS to droop market agreements with brokers and brokers for as much as 90 days, when there’s proof of fraud or abusive conduct. In instances of extreme misconduct, HHS can terminate the agent or dealer’s settlement with {the marketplace}. In each instances, brokers and brokers can attempt to rebut the fees towards them and restore their capability to facilitate enrollments.

Noting that the method for reviewing agent and dealer rebuttal supplies is time intensive and sometimes requires assessment of advanced technical data and information, HHS is proposing to increase the timeframe for assessment. Particularly, HHS is proposing to offer itself as much as 45 days to assessment rebuttal proof from brokers and brokers who’ve had their market agreements suspended, and as much as 60 days to assessment submissions from brokers and brokers which have had their market agreements terminated.

The proposed rule would additionally require brokers, brokers, and web-brokers to doc that their shoppers (or licensed representatives) have reviewed and confirmed their eligibility data earlier than they submit an utility. The documentation would want to incorporate the date the buyer reviewed the appliance, the buyer’s title (or licensed consultant’s title), an evidence of the attestations within the utility, and the title of the agent, dealer, or web-broker offering the help. Brokers and brokers would want to keep up this documentation for not less than 10 years and have the ability to present it to HHS upon request.

HHS observes that it has obtained shopper complaints about brokers, brokers, or web-brokers submitting incorrect utility data on their behalf. The company notes that these complaints are tough to analyze as a result of they usually contain one individual’s phrase towards one other’s. HHS believes that requiring documentation that the buyer has reviewed and confirmed their utility data may assist with the adjudication and determination of such complaints. Though HHS wouldn’t prescribe precisely how brokers, brokers, and web-brokers ought to acquire the required documentation, they would supply a non-exhaustive record of acceptable strategies. The company seeks touch upon this proposal, together with data on present finest practices among the many agent/dealer neighborhood.

The proposed rule would additionally require FFM and SBM-FP brokers, brokers, and web-brokers to doc that they’ve obtained a shopper’s consent to help them with a market eligibility utility. This consent would want to incorporate the date, the buyer’s title (or licensed consultant), and the title of the agent, dealer, or web-broker. Whereas the company declines to prescribe the type of consent, they observe that it may take the type of a signature or a recorded verbal authorization. The dealer, agent, or web-broker could be required to keep up a report of the consent for not less than 10 years and have the ability to produce it for HHS upon request. The company notes that they’ve obtained shopper complaints alleging that they had been enrolled in market protection with out consent. When investigating these complaints, HHS has discovered brokers and brokers who attest to receiving consent however can’t produce dependable information to defend themselves from the allegations.

Writer’s Be aware

The Robert Wooden Johnson Basis offered grant assist for the creator’s time researching and scripting this put up.

Sabrina Corlette, “Proposed 2024 Fee Rule, Half I: Insurance coverage Market Reforms and Shopper Help,” Well being Affairs Forefront, December 14, 2022, material/forefront/proposed-2024-payment-rule-part-1-insurance-market-reforms-consumer-assistance-and-risk © 2022 Well being Affairs by Venture HOPE – The Individuals-to-Individuals Well being Basis, Inc.