{"id":7669,"date":"2023-12-18T10:15:17","date_gmt":"2023-12-18T15:15:17","guid":{"rendered":"https:\/\/chirblog.org\/?p=7669"},"modified":"2023-12-18T10:15:17","modified_gmt":"2023-12-18T15:15:17","slug":"proposed-2025-payment-rule-marketplace-standards-and-insurance-reforms","status":"publish","type":"post","link":"https:\/\/chirblog.org\/proposed-2025-payment-rule-marketplace-standards-and-insurance-reforms\/","title":{"rendered":"Proposed 2025 Payment Rule: Marketplace Standards And Insurance Reforms"},"content":{"rendered":"\n

By Sabrina Corlette and Jason Levitis<\/em><\/p>\n\n\n\n

On November 15, 2023, the U.S. Department of Health & Human Services (HHS) released a proposed rule<\/a> to update standards that apply to Marketplaces and health plans under the Patient Protection & Affordable Care Act (ACA) for plan year 2025. In addition to the rule, referred to as the Notice of Benefit & Payment Parameters or informally as the \u201cPayment Rule” or “Payment Notice,\u201d HHS released a fact sheet<\/a>, a draft 2025 Letter to Issuers<\/a>, a proposed 2025 Actuarial Value Calculator<\/a> and methodology, and guidance<\/a> providing updated numerical parameters for 2025. Comments on the proposed rule are due within 45 days of the rule\u2019s publication in the Federal Register, and comments on the Draft Letter to Issuers are due on January 2, 2024.<\/p>\n\n\n\n

The proposed 2025 NBPP builds on several policy priorities of President Biden\u2019s administration. It includes proposals designed to expand Marketplace enrollment, improve the consumer experience, and raise standards for Marketplace plans nationwide. If finalized, these proposals will generally be effective on January 1, 2025, unless noted otherwise below.<\/p>\n\n\n\n

In this Forefront<\/em> article, we focus on market reforms, Marketplace standards, and Advance Premium Tax Credit policies. A second article by Matthew Fiedler<\/a> discusses HHS\u2019 proposals related to risk adjustment.<\/p>\n\n\n\n

A Federal \u201cFloor\u201d For The Health Insurance Marketplaces<\/h2>\n\n\n\n

In the first decade of the ACA\u2019s Marketplaces, the number of state-based Marketplaces (SBMs) has fluctuated from 15 in 2014 to a low of 12 in plan year 2017. Today<\/a>, 18 states and D.C. operate an SBM, the federal government operates 29 Marketplaces, and three states run a Marketplace in partnership with HHS. Two more states, Georgia<\/a> and Illinois<\/a>, are expected to transition to an SBM for plan year 2025. Several other states are also considering transitions. In light of this, the administration makes several proposals that would set minimum national standards for the operation of the Marketplaces and the plans they offer.<\/p>\n\n\n\n

A Graduated Transition<\/h3>\n\n\n\n

HHS proposes that a state seeking to operate an SBM must first operate as an SBM using the federal platform (SBM-FP) for at least one year, including during an open enrollment period. SBM-FPs conduct plan management, conduct outreach, and provide consumer assistance, but the eligibility and enrollment functions are performed by the federal government, through HealthCare.gov<\/a>. HHS notes that building and maintaining an SBM requires \u201cextensive start-up resources,\u201d including investments in relationships with consumers, consumer assisters, eligibility and enrollment partners, insurers, and other parties.<\/p>\n\n\n\n

Operating an SBM-FP for at least one year before taking on full operation of an SBM allows states time to implement critical eligibility and enrollment functions, contract with IT and other vendors, and coordinate with state partners such as Medicaid agencies and departments of insurance. The administration seeks comment on this proposal, including on whether a year is an appropriate duration of time for a state to operate as an SBM-FP before transitioning to an SBM.<\/p>\n\n\n\n

A More Rigorous Approval Process<\/h3>\n\n\n\n

HHS proposes to require that states seeking to transition to an SBM submit supporting documentation to HHS through the Exchange Blueprint<\/a> process. The Blueprint outlines the state\u2019s plans for standing up and operating an SBM and must be approved by HHS. Under this proposal, states would be asked to submit detailed plans regarding consumer assistance programs and activities. It also would clarify that HHS has the authority to request any evidence necessary to assess the state\u2019s ability to meet requirements for SBM functionality.<\/p>\n\n\n\n

Additionally, HHS proposes that states be required to provide the public with notice and a copy of its Blueprint application at the time of submission; HHS would publicly post the state\u2019s application within 90 days of receipt. At some point after submitting the Blueprint application, states would be required to conduct at least one \u201cpublic engagement,\u201d such as a townhall meeting. Further, until the state has received formal HHS approval for its SBM transition, it would be required to periodically conduct similar public engagements at which the public could learn about the state\u2019s progress towards establishing an SBM.<\/p>\n\n\n\n

Standards For Call Centers<\/h3>\n\n\n\n

All Marketplaces must, under current law, operate an accessible, toll-free call center that can respond to consumers\u2019 requests for assistance. Once an SBM is established, HHS monitors call center operations through annual data reports that document call volume, wait times, abandonment rates, and average call handle time. While HHS declines at this time to set minimum staffing levels for Marketplace call centers, they are proposing that SBMs meet the following additional requirements:<\/p>\n\n\n\n