The Centers for Medicare & Medicaid Services (CMS) on Monday released the 2024 Notice of Benefit and Payment Parameters Final Rule (final 2024 Payment Notice). The measures contained in the final rule, the agency said, will make it easier for millions of Americans to select a health plan in 2024.
The changes included in the 2024 Notice of Benefit and Payment Parameters Final Rule (final 2024 Payment Notice) are for issuers and marketplaces, but also include requirements for agents and brokers that help consumers enroll for coverage through marketplaces that use the federal platform. The provisions in the rule aim to advance health equity by addressing health disparities within the health system, such as strengthening network adequacy standards and creating a new special enrollment period for those who lose Medicaid or Children’s Health Insurance Plan (CHIP) coverage. The rule also expands access to behavioral health care and will make it easier to select and enroll in health coverage.
Here is a summary of the major changes:
Enrollment: Beginning January 1, 2024, federally-facilitated marketplaces and state-based marketplaces will have an option to create a special enrollment period (SEP) for people losing Medicaid or CHIP coverage, allowing consumers to select a plan for marketplace coverage 60 days before, or 90 days after, losing Medicaid or CHIP coverage. The SEP aims to reduce gaps in coverage and allows for a more seamless transition into marketplace coverage, CMS said in the announcement. The final rule also removes barriers so those who assist consumers with outreach and education can also help them enroll in coverage. CMS said the policy change will help improve health literacy in rural and underserved communities and reduce burden on consumers, especially for consumers with a lack of access transportation, inflexible job schedules, and those who are immunocomprised.
Health care access: The final rule expands access to behavioral health care by extending the requirement for plans to contract with at least 35 percent of available essential community providers (ECP) in a plan’s service area to apply to two individual ECP categories: Federally Qualified Health Centers and Family Planning Providers. The overall 35 percent threshold requirement remains in place. CMS said these changes, along with the expanded network adequacy requirements, will increase provider choice, advance health equity, and expand access to care for consumers who have low incomes, complex or chronic health care conditions, or who reside in underserved areas.
In a fact sheet, CMS said it will delay an amendment to the regulations regarding appointment wait times until plan year 2025. This will give qualified health plans an additional plan year before they must attest to meeting appointment wait time standards. CMS will release guidance later on how to comply with this standard, including how issuers should collect data from providers and how to interpret metrics.
Plan selection process: CMS will make it easier for people to select a health plan that meets their needs and budget by limiting and refining designs for standardized plan options. Issuers of qualified health plans through the federal marketplaces and state-based marketplaces may only offer four plan options in each area for the 2024 plan year.
User fees: For the 2024 benefit year, CMS finalized a user fee rate of 2.2 percent of premium for qualified health plans sold on the federally-facilitated marketplaces and a user fee rate of 1.8 percent of premium for qualified health plans sold on state-based marketplaces.
Risk adjustment: CMS has finalized the use of 2018, 2019, and 2020 enrollee-level EDGE data for model recalibration for all coefficients, with no exceptions, for the 2024 benefit year risk adjustment models. Using the three most recent consecutive years for recalibration of the risk adjustment models will provide stability and minimizes volatility in changes to risk scores between benefit years due to differences in the dataset’s underlying populations, while reflecting the most recent years’ claims experience available, according to CMS. In addition, CMS has also finalized:
- Beginning with the 2023 benefit year, the proposal to collect and extract from issuers’ EDGE servers a new data element, a Qualified Small Employer Health Reimbursement Arrangement indicator, including the phased implementation approach, as well as to extract plan ID and rating area data elements issuers have submitted to their EDGE servers from certain benefit years prior to the 2021 benefit year.
- A risk adjustment user fee for the 2024 benefit year of $0.21 per member per month.
- Repeals the ability of prior participant states to request a reduction in risk adjustment state transfers calculated by the Department of Health and Human Services (HHS) under the state payment transfer formula in all state market risk pools starting with the 2025 benefit year.
HHS risk adjustment data validation (RADV): Beginning with the 2021 benefit year of HHS-RADV, CMS will no longer exempt exiting issuers from adjustments to risk scores and risk adjustment transfers when they are a negative error rate outlier in the applicable benefit year’s HHS-RADV results. The agency also changed the materiality threshold for random and targeted sampling for HHS-RADV participation from $15 million in total annual premiums statewide to 30,000 total billable member months statewide, beginning with the 2022 benefit year of HHS-RADV. CMS will also shorten the window to confirm the findings of the Second Validation Audit or file a discrepancy report, to within 15 calendar days of the notification by HHS, beginning with the 2022 benefit year of HHS-RADV. Further, CMS will also discontinue the use of the lifelong permanent condition list and the use of non-EDGE claims in HHS-RADV beginning with the 2022 benefit year of HHS-RADV, to better align HHS-RADV policies and the EDGE Server Business Rules used for EDGE data submissions.