CMS Completes Revisions to ACA Exchange Regulations for Insurers

The Centers for Medicare & Medicaid Services (CMS) will require that insurers participating in the Affordable Care Act exchanges include mental health and substance abuse providers among other things.

The final rule announced on Monday softens CMS proposed limits on the number of exchange plan options insurers can provide. It also abandons agency proposals that standardize how carriers market their drug formularies, and differentiate similar plans within a particular market. The final rule also reduces the fees that insurers have to pay in order to market their products through federal and state exchanges.

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State-based marketplaces can implement a special period of enrollment for enrollees who lose Medicaid or Children’s Health Insurance Program. The window is 60 days prior to losing coverage and 90 days after. The first day of the month would be the effective date for coverage.

This follows a similar CMS move in January that was made for Healthcare.gov members who lost coverage when states began to unwind their Medicaid rolls for first time in over two and a half years.

Also, the agency finalized plans for reducing the number of options in insurance and cracking down on plan names that are misleading. CMS will require that carriers submit their plan names to the federal or state government for approval.

The CMS proposed that carriers be limited to only two non-standard plan options per category and did not offer the option of excluding dental or vision benefits.

According to federal data, the agency has set a limit on how many plans it can offer. The number of options available to consumers increased from 27 in 2019 up to 131 by 2023. CMS expects that the final rule will reduce the number of plans on exchanges from 90.5 to 90.5.

The final rule for 2024 includes provisions that will crackdown on broker’s sales tactics, increase navigators enrollment flexibility, reduce exchange fees, and more. What you need to know.

  • CMS will require that insurers market their coverage for substance use disorders, mental healthcare treatments, federally-qualified health centers, and family planning providers, by organizing providers into different categories and instructing them to include at least 35 percent of such clinicians within their networks.
  • The regulators abandoned their plan that would have required carriers to standardize the way they cover generic, specialty and brand drugs. After insurers complained that the agency’s plan would limit their ability to customize formularies, they dropped it. CMS will continue to examine the market implications of this proposal.
  • The agency has abandoned its plan to require an “meaningful differences” standard between insurers. This would have required that plans offered by the exact same company, in the same region and at the same level of metal, have a difference in the deductible greater than $1,000.
  • Navigators funded by the federal government can visit consumers at their homes to enroll them and conduct outreach. They will also sign up new customers during their initial meeting.
  • Brokers are required to confirm the income of their customers and any other personal information with them before they submit applications. CMS wants to extend the time frame in which the Health and Human Services Department can act on complaints from consumers against brokers. Brokers are required to retain all electronic and telephonic interactions they have had with their customers for a minimum of 10 years.
  • On both federal and state markets, the user fees that insurers are required to pay for marketing their products have been reduced by almost 0.5%. The carriers would have to pay premiums of 2.2% for plans on federal marketplaces and 1.8% for plans on state marketplaces. CMS initially sought a reduction that was half as large.
  • CMS will update risk-adjustment information that plans are required to submit by 2024 and charge insurers an annual fee per member for the calculation of what they owe under the federal program. Under the risk-adjustment plan, plans that cover healthier customers are required to contribute money into a pool of insurers who have sicker policyholders and higher costs.
  • The agency will change the automatic enrollment process to redirect low-income consumers who qualify for cost sharing reductions to Silver plans that have similar provider networks as their current Bronze plans.

is a writer for Crain’s sister magazine.