CMS on Friday significantly changed how Affordable Care Act exchanges will run next year, intending to lower out-of-pocket costs for Obamacare customers, streamline enrollees’ user experience and update how insurers are paid for the risks they take on their members.

In its second update to the annual benefit and payment parameters rule, the agency announced consumers’ maximum out-of-pocket costs will be limited to $8,700 for individuals and $17,400 for plans that cover multiple people. The update is $400 lower than previous caps, CMS said.

Officials said they curbed cost-sharing parameters by citing the National Health Expenditure Accounts’ projections of per-enrollee, employer-sponsored insurance premiums. CMS said this was the measure used for benefit years 2015 through 2019.

“Families deserve to have access to healthcare coverage that doesn’t break the bank. That’s why today we’re acting to lower consumers’ maximum out-of-pocket costs by $400 and why President Biden has a plan to reduce families’ healthcare costs for the long run,” HHS Secretary Xavier Becerra said in a statement.

CMS said it was also finalizing a few provisions aimed at helping consumers gain coverage. During this special enrollment period, CMS said 80,000 individuals have already enrolled in plans.

By allowing enrollees to change marketplace plans if they don’t receive advance payment on premium tax credits; allowing those age 30 and over to apply for catastrophic coverage; enabling beneficiaries who aren’t notified of triggering life events to enroll in plans 60 days after they learn about their eligibility; and permitting COBRA beneficiaries to sign up for marketplace coverage if the employer or government contributions to their plan end, the agency aims to slow the growth in healthcare costs and cut the uninsured rate.

“The ACA and the American Rescue Plan offer a lifeline to coverage for millions who might otherwise be uninsured,” CMS Acting Deputy Administrator Jeff Wu said in a statement. “Those groundbreaking legislative actions are lowering health insurance premiums for millions of Americans, and the regulatory steps we’re taking today build upon those actions. They will ensure that next year, Americans will continue to find affordable, quality coverage through the marketplaces.”

The updated notice outlines a few measured officials to improve transparency within CMS and HHS operations and across the healthcare industry.

By surveying and posting annual reports on individuals’ experience with the exchange, the CMS hopes to smooth users’ experience enrolling in coverage. Additionally, the agency is also clarifying its procedure for auditing insurers’ advance premium tax credit, cost-sharing reductions and user fee programs. It now has the authority to penalize payers who violate these standards, regardless of whether they’re on state or HHS-operated exchanges.

Officials will also require direct enrollment entities, like brokers, to display and market qualified health plans, individual benefit products and coverage plans that meet ACA rules on their websites, in most circumstances. Pharmacy benefit managers will be required to tell HHS how much they paid for drugs. The CMS also moved to continue price-adjustment for hepatitis C drugs.

The updated notice also outlines a few parameters and requirements insurers need to design plans and set rates for 2022.

Among insurer provisions enacted, CMS mandated that payers report the lower, adjusted plan premiums billed to enrollees who receive temporary premium credits. Officials have also updated HHS’ schedule for collecting risk-adjustment data validation, or RADV, payments to the same year that RADV results are released. Finally, CMS will allow insurers to use the three most recent consecutive years of enrollee data for calculating their risk-adjusted model recalibration.

HHS also set a deadline for states to submit their essential health benefits benchmark plan selections for 2024 and finalized the term for states to submit their 2022 annual reports on required benefits. The HHS will not penalize states that do not submit annual reports for 2021. Officials also approved Alabama’s request to cut risk adjustment state transfers by 50% in the individual and small-group markets in 2022.

The first 2022 payment notice rule was released in January, and CMS said it anticipates making additional rules to payment policies later this year.



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