CMS proposes changes to ACA network adequacy, standardized planning rules

According to a draft regulation released Monday, the Centers for Medicare and Medicaid Services aims to reduce the number of non-standard policies offered on health insurance exchanges while increasing availability of providers in the service provider’s network.

The proposed rule would require participating health insurance companies to comply with state and federal network coverage standards and would review their contracts with regulatory centers. substance use disorder treatment and mental health facilities to ensure providers are available to members. CMS will require insurance companies to promote their coverage of substance use disorders and psychiatric treatments by organizing providers into separate categories and guidelines. Insurers include at least 35% of their providers in any particular market in their networks.

The agency also aims to increase the availability of standardization plan and limit the number of non-standardized health plans sold on exchanges. CMS will limit the number of denormalized packages that carriers can offer for every type of network at each metal level to two. According to a CMS fact sheet, the average number of plans for consumers has skyrocketed from 27 in 2019 to 131 in 2023.

For example, exchange insurers can only sell two gold, non-standard HMOs and two gold, non-standard PPOs per service area. The agency is considering asking insurers to group plans by county, metal grade, product type, etc., as a way to simplify comparative shopping. This requirement will only apply to insurance companies that sell in states that use the federal marketplace platform.

Regulation predicts that the Children’s Health Insurance and Medicaid eligibility redetermination process will begin when the federal government’s COVID-19 public health emergency ends effect. CMS proposes setting up a special subscription period for those who lose Medicaid or CHIP benefits because their incomes increased during the pandemic, when states weren’t allowed to cut their benefit roles in exchange for federal COVID-19 relief. An estimated 18 million low-income adults and children could lose coverage when the emergency designation expires, according to the Robert Wood Johnson Foundation. The public health emergency is currently scheduled to end in April.

The 2024 Notice of Benefits and Payment Specifications proposed rule also includes provisions to:

  • Reduced user fees charged by insurers by 0.25% in both the federal and state markets. Carriers will pay a 2.5% premium for plans sold in the federal market and 2% premium for plans sold in the state market.
  • Allows exchange navigators to visit individuals’ homes and help them apply for health insurance on their first visit. Navigators are now allowed to visit customers’ homes, but are not allowed to register them the first time they meet.
  • Update the risk-adjusted data that plans must file for 2024 and charge each member of the insurance company to calculate how much they owe or are owed under the federal program. The risk-adjusted program requires plans that insure healthier customers pay out to insurers whose policyholders are sicker and more expensive.
  • Modify the automated application process for low-income consumers to direct those eligible for cost-sharing reductions to silver plans with a provider network similar to current bronze plans their.
  • Review package names to make sure they accurately describe the product. CMS will require plans to submit a marketing name for their plan for federal or state approval.
  • Ask the broker to confirm with the client about income and other personal information before submitting the application. CMS aims to extend the time it takes for the Department of Health and Human Services to resolve consumer complaints against brokers.


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