In an effort to build on the Affordable Care Act and reduce healthcare costs, the Centers for Medicare & Medicaid Services finalized a host of new rules that will govern the ACA federal exchanges next year.
The second 2022 Notice of Benefit and Payment Parameters final rule was released Friday. It adds provisions to the first part of the final rule, which was adopted in January.
Here are five of the new provisions CMS adopted through the second rule:
1. Limits on cost-sharing
CMS is setting the final required contribution percentage for 2022 at 8.09%. Concurrently, the maximum out-of-pocket costs for consumers have been limited to $8,700 for individual coverage and $17,400 for plans that cover several people. This limitation on maximum cost-sharing is $400 below what CMS proposed last November, the agency said.
2. Special enrollment period policies
CMS is adopting policies that loosen restrictions on signing up for a special enrollment period (SEP), which enables consumers to get coverage through the ACA exchanges outside of open enrollment.
Consumers can qualify for a SEP in the event of certain triggering life changes, like getting divorced or losing a job. Those who qualify have 60 days from the date of the event to select a new health plan.
A Deep-dive Into Specialty Pharma
A specialty drug is a class of prescription medications used to treat complex, chronic or rare medical conditions. Although this classification was originally intended to define the treatment of rare, also termed “orphan” diseases, affecting fewer than 200,000 people in the US, more recently, specialty drugs have emerged as the cornerstone of treatment for chronic and complex diseases such as cancer, autoimmune conditions, diabetes, hepatitis C, and HIV/AIDS.
Per the new policy, consumers can qualify for a SEP if they did not receive timely notice of a triggering life event or were “otherwise reasonably unaware that a triggering event occurred,” CMS stated.
Further, CMS is adopting a policy allowing individuals with Consolidated Omnibus Budget Reconciliation Act (COBRA) coverage to qualify for a SEP if employer contributions or government subsidies cease.
“These SEP policies will offer greater flexibility for those who need coverage — particularly those communities hardest hit by Covid-19,” the agency said in a news release. “Already, an additional 800,000 Americans have enrolled in the ACA under the SEP enacted by the administration.”
3. Website display requirements for direct enrollment entities
CMS codified a new web display requirement for direct enrollment entities, that is, qualified health plan issuers and third-party web-brokers who enroll consumers in coverage on the exchanges directly from their websites.
With some narrow exceptions, the rule requires direct enrollment entity websites to display the following three categories of plans across at least three distinct web pages next year: qualified health plans offered through the exchange; individual health insurance coverage subject to ACA market-wide rules offered outside the exchange; and all other products, such as excepted benefits not subject to ACA rules.
4. Transparency in pharmacy benefit management
CMS will collect prescription drug data directly from pharmacy benefit managers in 2022. The agency plans to use the data to better understand the true cost of prescription drugs provided in exchange plans “and shed light on the role that PBMs play in their cost,” CMS said.
5. Access to enrollee experience information
CMS will post a public use file for the results of the annual qualified health plan enrollee experience survey. The agency aims to make health plan quality more transparent, and this move will provide consumers, states, plan issuers and researchers access to enrollee experience data, CMS said.
“[These legislative actions] will ensure that next year, Americans will continue to find affordable, quality coverage through the marketplaces,” said Jeff Wu, CMS acting principal deputy administrator, in a news release. “Consumers and insurers alike will benefit from improvements in the 2022 payment notice.”
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