{"id":7222,"date":"2023-04-26T09:25:00","date_gmt":"2023-04-26T13:25:00","guid":{"rendered":"https:\/\/chirblog.org\/?p=7222"},"modified":"2023-04-25T14:26:54","modified_gmt":"2023-04-25T18:26:54","slug":"final-2024-payment-rule-part-1-insurance-market-rules-and-consumer-assistance","status":"publish","type":"post","link":"https:\/\/chirblog.org\/final-2024-payment-rule-part-1-insurance-market-rules-and-consumer-assistance\/","title":{"rendered":"Final 2024 Payment Rule, Part 1: Insurance Market Rules And Consumer Assistance"},"content":{"rendered":"\n

On April 17, 2023, U.S. Department of Health & Human Services (HHS) released its final rule<\/a> to update requirements and standards for health insurers and Marketplaces under the Affordable Care Act (ACA) for plan year (PY) 2024. In addition to this annual \u201cNotice of Benefit & Payment Parameters,\u201d (NBPP) the agency released a Fact Sheet<\/a> about the final rule, and the final PY 2024 Actuarial Value (AV) Calculator<\/a> and Methodology<\/a>.<\/p>\n\n\n\n

HHS received over 300 public comments<\/a> on its draft NBPP, and in this final rule advances proposals to prohibit Marketplace plans without a provider network, limit the profusion of non-standardized plans, encourage enrollment in plans with reduced cost-sharing for lower-income consumers, reduce deceptive marketing practices, and lower administrative barriers to enrollment. It also finalizes modifications to risk adjustment, Advance Premium Tax Credit (APTC) policy, marketplace transitions, user fees, and other marketplace standards. Key themes underlying many of the 2024 rules are the administration\u2019s commitment to advancing health equity, improving the consumer experience, and expanding Marketplace enrollment.<\/p>\n\n\n\n

In this first of three Forefront articles on the final 2024 NBPP, we focus on market reforms and consumer assistance. The second and third articles focus on\u00a0risk adjustment<\/a>,\u00a0proposed changes to marketplace operational standards, and APTC policies<\/a>.<\/p>\n\n\n\n

Network Adequacy And Essential Community Providers<\/h2>\n\n\n\n

The 2024 NBPP maintains the network adequacy standards for Marketplace health plans, implemented by the Biden administration in plan year 2023, with modest changes. The administration is also ratcheting up its expectations that Marketplace issuers include essential community providers (ECPs) in their plan networks.<\/p>\n\n\n\n

Plans That Do Not Use A Provider Network<\/h3>\n\n\n\n

The ACA requires that Marketplace plans ensure a \u201csufficient choice\u201d of providers and provide information to enrollees about the availability of in-network and out-of-network providers. The statute also requires that plans \u201cinclude within health insurance plan networks those essential community providers, where available, that serve predominantly low-income, medically-underserved individuals.\u201d In the proposed 2024 NBPP, HHS argued that issuers cannot comply with the ACA standards, and the agency cannot effectively enforce compliance, if a plan does not use a provider network. The agency has observed that plans without provider networks can result in access and affordability challenges for enrollees, including substantial and unexpected out-of-pocket costs. Under the ACA, the Marketplace has broad discretion to certify a plan for participation only if determines that doing so is \u201cin the interests\u201d of consumers.<\/p>\n\n\n\n

The agency therefore proposed to repeal a 2016 policy that exempted Marketplace plans, stand-alone dental (SADP), and small business health option program (SHOP) plans that do not maintain a provider network from the ACA\u2019s network adequacy requirements.<\/p>\n\n\n\n

Since 2016, only a single health plan issuer on the federally facilitated Marketplace (FFM) has sought certification without a provider network. For SADPs, only 8 of the 672 participating in the Marketplace in 2022 did not use a network of providers, a number that has declined each year since 2017. In this current plan year, SADPs without a provider network are concentrated in just two frontier states<\/a>, Alaska and Montana.<\/p>\n\n\n\n

HHS is finalizing its requirement that Marketplace health plan, SADP, and SHOP issuers maintain a provider network beginning in PY 2024. Most commenters supported the proposal.<\/p>\n\n\n\n

However, HHS estimates that approximately 2,200 SADP enrollees could be required to switch plans under this policy. To try to mitigate this risk, HHS is creating a \u201climited exception\u201d for SADP issuers in areas where it is considered \u201cprohibitively difficult\u201d to establish a network of dental providers. This determination must be made based on attestations from state insurance regulators in states where at least 80 percent of their counties are classified as Counties with Extreme Access Considerations that at least one of these factors exists:<\/p>\n\n\n\n