The Centers for Medicare and Medicaid Services (CMS) issued its annual proposed Notice of Benefit and Payment Parameters (NBPP) on December 28, 2021. This important set of proposals will impact enrollees, health plans, web brokers, the Federally Facilitated Marketplace (FFM), State-based Marketplaces using the Federal Platform (SBM-FP), and State-based Marketplaces (SBMs). Stakeholders were encouraged to submit their comments on the proposals with the intention of impacting the future of health insurance offerings.
Health Plans Must Adapt to Changing Requirements for Plans and Enrollment Support
Cost-Sharing Limits
Health plans must accommodate the shift in the maximum limit on cost sharing for health insurance policies applicable in both FFM and SBM states. In 2022, the annual limit on cost-sharing is $8,700 for self-only coverage and $18,200 for other than self-only coverage. CMS would update these amounts to $9,100 for self-only coverage and $18,200 for other than self-only coverage in 2023. (CMS is making these updates through a separate guidance document issued around the same time as the NBPP.)
Health plans should have policies in place to update cost-sharing limits and understand how these changes will impact available plans and coverage types.
Annual Health Plan Renewals Processes
Currently, FFM enrollees are re-enrolled into the same plan from one year to the next. Since plans and premium subsidy amounts change each year, a plan that was a good choice one year becomes a bad choice the next. CMS proposes changing the approach to eligibility redeterminations by incorporating out-of-pocket costs, premiums, and plan generosity into the automatic reenrollment hierarchy. Considering member behavior and plan details allows the automated reenrollment processes to make more informed decisions and possibly increase member retention.
Policies on Guaranteed Availability of Coverage
Under rules issued during the Trump Administration, carriers can decline to effectuate coverage for consumers who have past-due premiums from a previous enrollment. Under the proposed rule, insurers would no longer be able to deny coverage to applicants with outstanding debt from previous coverage. This policy would apply nationwide – in both FFM and SBM states.
Reinstating coverage to those with past-due premium payments may present new administrative complexities for health plans. Tracking and targeting members with an outstanding balance in efforts to retain the member requires automated communication informed by member behavior.
Health Plan Network Adequacy Reviews
The Biden Administration proposes to reinstate CMS-run health plan network adequacy reviews – a policy last active during the Obama Administration. Under this proposal, CMS would require carriers offering plans on the FFM to meet quantifiable standards for network access. Health plans would be required to meet new standards including maximum appointment wait times and travel distances to providers.
CMS proposes requiring plans to undergo a prospective network adequacy review before being marketed or sold in FFM and SBM-FP states. Reducing and setting requirements on plans sold on the marketplace would prevent health plans from submitting an overabundance of plan offerings that offer little variation.
Currently, SBMs conduct their own network adequacy reviews. CMS expressed a need for greater alignment of network adequacy reviews across FFM and SBM states. Potentially mandating network adequacy standards in SBMs grants CMS greater oversight to facilitate changes that would be consistent across the FFM, SBM-FP states, and SBMs.
Health plans must plan for the release of stricter requirements regarding network adequacy reviews. Plans approved in the past may need to be revisited and modified to stay on the Marketplace. Efforts like these are designed to curb the influx of new plans entering the Marketplace as we saw during 2021.
CMS Proposes Greater Restrictions for Web Brokers to Protect Enrollees
Display Requirements for Web Brokers
CMS proposes to bar web-brokers from using advertisements or other preferential displays for QHPs based on the compensation they would receive.
Web brokers would be required to display the same QHP comparative information as HealthCare.gov including:
- Premiums
- Cost-Sharing Information
- The Summary of Benefits and Coverage
- Metal Level Data
- Enrollee Satisfaction Survey Data
- Quality Ratings Data
- Plan’s Provider Director
CMS aims to clarify that web-brokers are prohibited from favoring certain plans due to payment from carriers. In this same spirit, the rule proposes requiring web brokers to display an informed rationale for all their plan recommendations. Additionally, brokers would need to provide a rational and methodology for selecting plan displays on their website.
Broker Enrollment Rules
CMS has become concerned that certain agents, brokers, and web-brokers were completing the marketplace application process without a consumer’s consent or knowledge.
When this occurred, brokers would submit income information that resulted in a $0 monthly premium. Brokers would receive commissions from carriers, and consumers might not discover they’d been erroneously enrolled in a plan until tax time – when they suddenly owed money to the IRS.
To prevent this from happening, CMS proposed several restrictions to ensure that the email address, telephone number, mailing address, and income information entered on applications submitted by agents, brokers, or web-brokers are valid.
These restrictions only apply to FFM agents, brokers, and web-brokers, but this problem has occurred in SBM states as well. Because of this, CMS recommends that SBMs also take action to address fraudulent marketplace submissions.
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Josh Schultz
Josh Schultz is a Senior Policy Analyst at Softheon, where he advises the company on health policy issues affecting businesses and government health agencies. Prior to Softheon, Josh worked for a non-profit agency assisting Medicare beneficiaries, a technology company, and consulting firms.
