CMS Completes Standardization of ACA Plan, Network Adequacy Policy

Insurers on Affordable Care Act exchanges will be required to offer plans with standardized deductibles and limits on out-of-pocket spending and co-payments for each of the non-standardized offerings, and meet stricter network adequacy requirements in 2023 according to the new Center. the final rule for Medicare and Medicaid services released Thursday.

CMS did not finalize a change to the risk-adjustment model for exchange plans that experts warned could encourage insurers to choose healthier consumers, and shelved a proposed policy explicitly banning discrimination based on sexual orientation and gender as a future rule.

The policy builds on an Obama-era initiative that was later canceled by Trump’s CMS. The Biden administration goes even further, requiring standard plans to be offered when insurers have non-standard options. CMS also says the policy change will support President Joe Biden’s 2021 executive order to promote competition in the economy.

Insurance lobbying group AHIP opposed the policy when it was proposed in January, saying it could overload choices for consumers. But patient advocates welcomed the rule. According to Carl Schmid, executive director of the HIV+Hepatitis Policy Institute, standardized plans will make it easier for patients to get their medicines.

“We only wish the Biden administration would apply these principles to more metals and drug levels, but it presents a better opportunity for people who rely on prescription drugs,” Schmid said in a statement.

The final rule will require qualified federally marketed health plans to have enough network providers for a certain amount of time and within a certain distance of members starting in 2023. Next year, insurance companies will also have to make sure their plan networks meet minimum waiting times. standards.

Insurers expressed concern over changes in network adequacy in January. AHIP stated that CMS should rely on government regulators in states that already use quantitative standards to test for adequacy. Other insurance groups have said such a policy would not be possible during the COVID-19 public health emergency.

CMS has abandoned its plan to change the risk adjustment of swap plans in a way that the agency says will better predict insurers’ costs for healthier participants. Health policy experts outside the agency warned CMS that the policy could make healthier participants more attractive to insurers at the expense of sicker people.

CMS has finalized a policy to improve risk adjustment calculations for part-year members.

CMS has also formally clarified that only expenditures on quality improvement activities directly related to the quality of care can be included in the loss rate reporting. Some insurers previously accounted for expenses such as overhead, marketing, lobbying, office space, executive salaries, corporate travel and wall art as incurred losses.

The final rule requires insurers to use clinical data to establish limits on basic medical benefits and coverage requirements. But CMS decided not to finalize the part of the proposed rule that would have repealed Trump-era policies that removed sexual orientation and gender identity from CMS anti-discrimination rules.

The Department of Health and Human Services is developing a separate proposed rule to eliminate prohibited discrimination in health insurance based on sex. HHS wants to review the proposed non-discrimination policies in a future rule to ensure they meet the requirements to be included in a separate non-discrimination rule, according to the rule fact sheet. The agency said it will continue to enforce the prohibition of discrimination based on sexual orientation and gender identity in health insurance until future regulations are passed.

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