5 things to know about CMS’ proposed rule for exchange plans

The Centers for Medicare and Medicaid Services recently released its annual proposed rule on Affordable Care Act marketplace reforms. Here are five elements of the sweeping proposal, known as the notice of benefit and payment parameters, to keep on your radar:

1. The Biden administration wants to explicitly reverse a Trump-era policy that removed sexual orientation and gender identity from CMS’ non-discrimination regulations. The provision would stop exchanges, insurance issuers, agents and brokers from discriminating against consumers for their sexual orientation or gender identity. The proposed rule also suggests requiring essential health benefits, guaranteed by exchange plans, to be designed based on clinical evidence. That could lead plans to offer similar coverage for medically necessary care, according to Katie Keith, a health law professor at Georgetown University.

2. CMS proposed requiring issuers in the federally funded exchanges and state-based exchanges run on the federal platform to offer standardized plans—offerings with fixed deductibles and limits on out-of-pocket costs and co-pays—alongside each of their non-standardized offerings. Issuers wouldn’t need to offer standardized options for product network types, plan levels or in service areas where they don’t already offer plans. This would build upon a 2017 Obama administration initiative, later undone by the Trump CMS, by going a step further to actually require standardized plan offerings.

3. CMS wants to maintain user fees from the 2022 plan year in 2023, meaning consumers would pay 2.75% of their monthly premiums for the federal exchange user fee and 2.25% of their premiums for using state-based exchange run through the federal platform. The premium adjustment percentage is about 1.44% for 2023, which CMS set out in guidance to go along with the proposed exchange rule. The maximum annual limit on cost sharing for 2023 is $9,100 for self-only coverage and $18,200 for other coverage. The guidance says this is about a 4.6% increase about the 2022 percentages.

4. The proposed rule offered several changes to the risk adjustment model in 2023, including suggesting that insurers gather and disclose additional data to CMS’ enrollee data servers. Under the proposal, insurers would have to collect data on enrollee zip codes, race ethnicity, enrollment in an individual coverage health reimbursement arrangement and a subsidy indicator. If finalized, this move could give the Health and Human Services Department space to craft more policies grounded in health equity evidence, Keith said.

5. The agency also asked for comments on ways HHS can incentivize qualified health plans to incorporate health equity into their design and to tackle social determinants of health. The agency also will accept comments on how insurers can address health impacts of climate change and how to make plan choice less overwhelming for consumers. Comments on these questions and other parts of the rule are due January 27.

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