CMS Exchange Plan Rule Addresses Equity, Quality, Standardization

 "With this proposed rule, we are working to ensure the Marketplaces are a model for accessible, affordable, inclusive coverage—particularly for eligible individuals who have thought comprehensive coverage was out of reach."— CMS Administrator Chiquita Brooks-LaSure

On December 27, 2021, CMS released its annual proposed rule governing Marketplace plans. The agency states that this notice of benefit and payment parameters is intended to "improve shopping for healthcare coverage, establish rules to ensure people can access care, and advance health equity for consumers purchasing Marketplace coverage … particularly for eligible individuals who have thought comprehensive coverage was out of reach.” To achieve these aims, the rule includes the following four proposals below as well as others designed to further stabilize the exchanges.

CMS also states that the proposed rule "minimizes the number of significant regulatory changes to provide states and issuers with a more stable and predictable regulatory framework that facilitates a more efficient and competitive market." Established payers and startup plans should welcome the news, if they agree with the agency's assessment.

Equity reinstatements, requirements, and requests

The proposed rule would once again prohibit discrimination on the basis of sexual orientation or gender identity, an established provision reversed during the Trump administration. The provision applies to covered services

Another equity-related measure would give HHS access to more granular data related to social determinants of health (SDOH). This includes ZIP code, race, ethnicity, and subsidy information. The rule would require that plans collect this data—many of whom already do or plan to improve their efforts—and report it to HHS. The agency has signaled it will use the data for risk assessment and adjustment and broader equity study—including, for example, "conducting analysis on whether there are any cost differentials for certain conditions based on race, ethnicity or subsidy indicator."

CMS has also requested comments on how it can incentivize plans for their health equity programs while also requesting that insurers include equity approaches in their quality improvement (QI) strategies.

Standardization for ease and stability

Carriers on select platforms will be required to offer standardized plans. This includes plans sold on HealthCare.gov and states that manage most exchange functions except enrollment ("facilitated State exchanges"). Standardized plans are to offer identical deductibles and cost-sharing for every network, metal, and plan type and for every plan service area. Some State-based Marketplaces already offer standardized plans as reported by HHS and its Office of the Assistant Secretary for Planning and Evaluation (ASPE). The office notes the impact of "choice overload": nearly 73% of HealthCare.gov consumers encountering more than 60 plan options and the average is 100.

Clinically based benefit design

Equity is also aided by evidence. CMS wants to require plans to design essential benefits that are evidence-based. Benefits include equally accessible care for people with chronic conditions and a possible de facto medical necessity standard across essential benefits. The latter insight is credited to Katie Keith, a Georgetown University adjunct law professor and industry consultant.

Network adequacy, in size and type

The proposed rule would reinstate federal network adequacy reviews for facilitated State exchanges with a companion requirement that 35% of a service area's essential community providers (ECP) be in network.

Other provisions of the proposed rule include: maintaining consumer exchange user fees at current levels; eliminating most pre-enrollment SEP certification requirements; and defining how QI incentives, bonuses, expenses, and activities apply to medical loss ratio calculation.

Rule comments are due January 27, 2022, and the final rule is published in May.