CMS addresses provider availability and exchange regulations in the proposed rule

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diving letter:

  • CMS has proposed revised rules and regulations for insurers operating in Affordable Care Act marketplaces, including attempting to improve provider availability by revising network adequacy and fundamental standards for community providers, according to HHS guidance released Monday Notice of performance and payment parameters of 2024.
  • The proposed rule will require all marketplace plans to use providers that comply with network adequacy and core provider standards, removing an exception that these regulations do not apply to insurers that do not use a provider network. In addition, insurers must include at least 35% of providers in a given market in their networks.
  • The proposed regulations come as ACA Exchange, spurred on by financial incentives during the COVID-19 pandemic, reached record enrollment numbers this year.

Dive insight:

The CMS has increasingly aligned with health equity initiatives as the Biden administration increases its oversight of health care on social issues. The proposed standards, released on Tuesday, are an attempt to further the government’s “goals to promote health equity by addressing the health inequalities that underlie our health care system,” according to the agency.

Mental health facilities and substance use disorder treatment are also typically addressed, with CMS proposing new insurer categories for mental health facilities and substance use disorder treatment centers.

The agency’s focus is on mental health, as other agencies such as HHS have released plans to better integrate mental health and substance use disorder treatment into the healthcare ecosystem. The COVID-19 pandemic has exacerbated the country’s mental health crisis, with President Joe Biden stating in this year’s State of the Union address that mental illness affected nearly 53 million Americans in 2020.

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In addition to increasing provider availability, the CMS proposes limiting the number of non-standard plan options that issuers can offer on exchanges and increasing the availability of standardized plans. Standardized plans must standardize their deductibles, maximum deductible, and cost sharing for plans with the same cover metals.

The standardized plans are an attempt to help consumers make plan choices, according to CMS, as the average number of plans available on the ACA marketplace has increased from 26 in plan year 2019 to 114 in plan year 2023, resulting in “plan choice.” overload.”

Under the proposed rule, insurers could only offer two non-standard tariffs per network type per metal tier on federal marketplaces.

For example, a plan would be limited to offering two gold health maintenance organizations and two gold preferred provider organizations non-standard plan options in each service area in 2024 and beyond, the CMS said.

The rule also proposes additional flexibilities for those who lose coverage from Medicaid or the children’s health insurance program due to the end of the COVID-19 public health emergency. A recent analysis by the Robert Johnson Wood Foundation found that 18 million people and 3.2 million children would lose Medicaid health coverage at the end of the public health emergency.

Participants who lose coverage from Medicaid or the Children’s Health Insurance program beginning January 1, 2024 have 60 days before or 90 days after the end of coverage to enroll in another Marketplace plan through a special enrollment period. The proposed rule also allows marketplace plans to provide earlier coverage start dates for those who anticipate losing health coverage and would otherwise experience a gap in coverage.

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