HHS Releases Benefits Notice and Payment Parameters for Proposed Rule for 2023 | King and Spalding


On December 28, 2021, the HHS released a proposed rule governing plans issued in the Patient Protection and Affordable Care Act (ACA) markets beginning in plan year 2023 (the proposed rule).
Among other changes to the rules in effect for plan year 2022, the proposed rule would implement the following changes to the applicable ACA market plans:

  • CMS would conduct network adequacy reviews for all states in the Federal Government Facilitated Market (FFM) other than states that adhere to standards at least as stringent as the Federal Network Adequacy Standards and choose to d ‘carry out their own examinations. The federal standard would be based on the time, distance, and wait standards for appointments, and reviews would be performed during the qualified health plan certification process;

  • Issuers unable to meet the standard would be allowed to submit a rationale as to why the standards are not being met, what they are doing to meet them and how their customers will be protected in the interim. The HHS would review the submitted rationale to determine whether deviations from the standards are reasonable under the circumstances, such as local availability of providers and variables reflected in local models of care, and whether the plan’s offer through the exchange facilitated by the federal government would be in the interest of qualified persons and employers;

  • CMS would require issuers in FFMs and state-based markets on the federal platform to offer standardized plan options to each type of product network, plan level, and service area in which they offer. non-standardized plan options from plan year 2023. -the standardized plan is a plan with variations in the cost-sharing structure which may make it difficult to compare in terms of total expected reimbursable expenses (including premiums ) against plans with standardized cost-sharing structures;

  • CMS would prohibit marketplaces, issuers, agents and brokers from discriminating on the basis of sexual orientation and gender identity, characteristics that had been protected by the ACA until the publication of an HHS rule. 2020;

  • The proposed rule would refine the essential health benefits (EHB) non-discrimination policy by providing examples illustrating allegedly discriminatory scheme designs that violate the prohibition on discrimination based on age, health conditions and factors. socio-demographic. Under the proposed rule, an example of an alleged discriminatory EHB design provided by the HHS would be the inclusion of an age limit for hearing aid coverage, which would violate the prohibition of discrimination based on age in EHB coverage;

  • The proposed rule would relax the Special Enrollment Period (SEP) verification prior to enrollment so that verification would only be required for loss of minimum essential coverage, and not for any other type of SEP;

  • The proposed rule would update the Quality Improvement Strategy (SIQ) standards to require issuers to address health and healthcare disparities as part of their QIS;

  • The proposed rule would increase the threshold for essential Community supplier from 20% to 35%;

  • The proposed rule would make several changes to the risk adjustment models used in the ABA market, including the addition of a two-step weighted approach for adult and pediatric models; removing current disease severity factors from adult models and adding Hierarchical State Categories (HCC) enumeration model specifications to adult and pediatric models; and replacing the current enrollment duration factors with contingent enrollment duration factors at HCC; and

  • The proposed rule would prohibit the inclusion of overhead costs attributable to expenses related to quality improvement activities for the purpose of calculating the medical loss ratio.

The full text of the proposed rule is available here.

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