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CMS EXCHANGE PLAN RULE ADDRESSES EQUITY, QUALITY, STANDARDIZATION

Analysis  |  By Laura Beerman  
|   January 10, 2022


TOPICS

ACA
CMS
consumers
costs
healthcare access
health insurance
policy


 "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

--------------------------------------------------------------------------------


KEY TAKEAWAYS

CMS puts health equity front and center through a focus on nondiscrimination,
data, and quality strategy proposals.

Plan and added benefit standardization recommendations are designed to improve
customer experience and uptake, while strengthening the Marketplace overall.

The government also seeks to address network adequacy for select State exchanges
and, more broadly, Essential Community Provider representation.

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



--------------------------------------------------------------------------------


GET THE LATEST ON HEALTHCARE LEADERSHIP IN YOUR INBOX.







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.







Laura Beerman is a contributing writer for HealthLeaders.



Photo credit: CALDWELL, IDAHO/USA - DECEMBER 6: View of the healthcare.gov
website in Caldwell, Idaho on December 6, 2013. Healthcare.gov is part of the
market place to buy health insurance.






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TAGGED UNDER:

ACA
CMS
consumers
costs
healthcare access
health insurance
policy

--------------------------------------------------------------------------------


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