HealthMatters
By Karen Davenport and Emma Walsh-Alker
Last November, the Centers for Medicare & Medicaid Services (CMS) released its proposed Notice of Benefit and Payment Parameters (NBPP) for plan year 2025. This annual rule governs the Affordable Care Act (ACA) health insurance Marketplaces and establishes standards for health insurers. The CHIR team has reviewed a sample of comments submitted by select stakeholder groups in response to the proposed rule.
For the first blog in our three-part series, we summarized comments from health insurers and brokers. In this second blog, we examine comments from consumer advocacy organizations:
Network Adequacy
For plan year 2025, CMS proposes that plans offered in state-based Marketplaces (SBMs) create state-specific network adequacy standards that are at least as stringent as the requirements that apply to plans on the federally facilitated Marketplace (FFM), These requirements focus on the time and distance enrollees must travel to see certain in-network providers. Under this proposal, SBMs would also be required to review plans’ networks for compliance with state standards prior to certification and sale on the Marketplace.
All of the consumer group comments we examined supported these proposals. Some advocates also asked that CMS go further—Community Catalyst and Families USA, for example, asked CMS to also apply the FFM’s pending appointment wait time standards to SBMs. Families USA also asked CMS to extend network adequacy standards to language access, cultural competency, and accessibility for people with disabilities and suggested requiring plans to make information on network adequacy publicly available. Advocates also pointed to inaccurate or out-of-date provider directories as an ongoing pain point for consumers; AARP asked CMS to explore strategies for improving the accuracy of provider directories, and Families USA requested that CMS promptly implement the No Surprises Act requirement to regularly update directory information.
Limits on Non-Standardized Plans
Beginning in plan year 2025, insurers offering plans on the federal Marketplace website, HealthCare.gov, will be limited to offering two non-standardized plan options per service area among three categories: product network type, metal level (except for catastrophic plans), and products that include dental and/or vision coverage. However, CMS has proposed an exceptions process that would allow insurers to offer additional non-standardized plans designed to lower cost-sharing for enrollees with chronic and high-cost health conditions.
While all of the consumer advocates in our sample expressed support for the underlying requirement that issuers on the FFM offer standardized plans, the proposed exceptions process elicited mixed responses and additional recommendations. AARP was the only group in our sample that explicitly expressed support for both the limit on non-standardized plan options and the proposed exception, arguing these policies would continue to improve consumers’ Marketplace shopping experience while also allowing for innovations to increase plan affordability.
Families USA, in contrast, felt they were unable to assert a position without more information about how the additional non-standardized plans would be designed and monitored to benefit the intended patient community. They asked that CMS report data on whether consumers with chronic conditions are actually enrolling in non-standardized plans and experiencing lower costs than they would have faced in a standardized plan option.
Enrollment Periods
The proposed NBPP includes several provisions concerning the timeframes and circumstances under which individuals and families may enroll in Marketplace coverage.
Standardized open enrollment period
While all Marketplaces using HealthCare.gov run open enrollment from November 1 through January 15, SBMs can determine their own enrollment periods (as long as open enrollment lasts until at least December 15 of the year preceding the relevant plan year). In practice, most SBMs adhere to the federal open enrollment period, but the proposed rule would require all SBMs, at a minimum, to align with the FFM’s open enrollment window and provide SBMs the option to extend open enrollment beyond January 15. CMS notes that this change would reduce consumer confusion and ensure that eligible individuals and families have sufficient time to enroll in Marketplace coverage.
Special enrollment periods
When consumers enroll on the FFM through a special enrollment period (SEP)—a mid-year enrollment opportunity triggered by the loss of coverage or another “qualifying life event”—coverage starts at the beginning of the month immediately following the enrollment date. Currently, some SBMs delay coverage effective dates if enrollment occurs in the latter half of the month. For example, in some states, if a consumer enrolls on July 16, their coverage would not be effective until September 1. This approach can leave consumers with a gap in coverage. CMS proposes requiring SBMs to align their coverage effective dates with the FFM.
Low-Income Special Enrollment Period
Most Marketplaces offer a monthly SEP for consumers with household incomes below 150 percent of the federal poverty level (FPL) and who qualify for Advanced Premium Tax Credits (APTCs). Between October 2022 and August 2023, nearly 1.3 million people enrolled in coverage on HealthCare.gov through this SEP. The low-income SEP is linked to the availability of temporarily expanded APTCs, which are authorized through 2025. In the NBPP, CMS proposes to de-link this SEP from enhanced APTCs, thus making the low-income SEP permanent.
All of the consumer groups in our sample voiced their support for aligning annual open enrollment periods and aligning coverage effective dates between the FFM and SBMs. In addition, ACS-CAN, Families USA, NHeLP, and Community Catalyst endorsed de-linking the low-income SEP from the availability of enhanced APTCs. NHeLP and Community Catalyst also requested that the Administration provide SBMs with additional flexibility to extend this SEP to individuals with incomes at or below 250 percent FPL.
Consumer Assistance Tools: Streamlining Standards for Web Brokers, Direct Enrollment Entities, and Call Centers
Call Centers
The proposed rule requires all current and future SBM call centers to meet minimum standards to ensure consumers are guaranteed access to assistance from a live representative during the call center’s hours of operation, rather than an automated system.
Web Brokers and Direct Enrollment Entities
The NBPP would also extend to SBMs the current federal standards for web brokers and direct enrollment (DE) entities that assist consumers with Marketplace eligibility and enrollment. This proposal would require web brokers to include disclaimers on their websites which clarify that they may not support enrollment in the full range of available plans and direct consumers to either HealthCare.gov or their state Marketplace website for more complete information. Similarly, the proposed rule sets national standards for DE entities, which include insurers and brokers that facilitate Marketplace enrollment through their own websites. DE entities in SBM states would be required to display Marketplace plans on a separate web page from off-Marketplace and other plans, as well as limit their marketing of non-Marketplace plans during open enrollment.
Consumer advocates generally supported these consumer assistance proposals in their comments. However, both NHeLP and Community Catalyst called for additional standards to ensure call centers are accessible and useful for consumers with limited English proficiency, disabilities, and those who cannot take time off from work during business hours to wait in a call center queue. Similarly, consumer advocates urged HHS to establish additional safeguards to mitigate risks that web brokers and direct enrollment entities can pose to consumers. For instance, Families USA encouraged HHS to prohibit web brokers from using screening tools that collect irrelevant information about a prospective enrollee’s health, while Community Catalyst called for HHS to prohibit brokers from marketing non-ACA-compliant products during open enrollment altogether, noting that this practice continues to mislead consumers.
Updates to Essential Health Benefit Benchmarks
CMS proposes several changes to the rules governing states’ selection of and updates to their essential health benefit (EHB) benchmarks. First, states would no longer need to “defray” the cost of a new benefit mandate if that benefit is already part of the state’s EHB benchmark plan. Second, CMS proposes changing two standards that currently constrain states’ policy choices for EHB. The proposed rule would eliminate the generosity standard, thus allowing states to propose EHB benchmarks that exceed the set of 2017 plans used as comparators. CMS is also proposing to update the typicality standard, which currently compares the EHB benchmark to a typical employer plan (defined as one of the ten base-benchmark options or one of the largest fully insured employer plans in the state). Under the proposed approach, states would only need to ensure that scope of benefits for their proposed EHB benchmark falls somewhere between that of the state’s least- and most-generous employer plan. This new floor-and-ceiling approach would allow states to adopt EHB benchmarks that more closely reflect current employer coverage.
The consumer advocates in our sample support these changes with some caveats and questions. ACS-CAN asked for clarification on whether the new defrayal policy applies across EHB categories or to services and items within EHB categories, citing the example of a state enacting legislation to mandate coverage of biomarker testing under the diagnostic test benefit already included in the state benchmark plan. Community Catalyst asked that CMS align the effective dates for changes to the defrayal policy and EHB selection. NHeLP expressed its general support for the proposed changes, but also shared long-standing concerns with CMS’s legal interpretation of the EHB provisions of the ACA, including CMS’s original decision to defer the definition of EHB to the states.
*Stakeholder comments on the proposal to allow the inclusion of adult dental services in the EHB will be discussed in a separate, forthcoming blog post.
A Note on Our Methodology
This blog is intended to provide a summary of comments submitted by consumer advocacy organizations. It is not intended to be a comprehensive review of all comments on every provision in the Notice of Benefit and Payment Parameters proposed rule, nor does it capture every component of the reviewed comments. To view more stakeholder comments, please visit https://www.regulations.gov/.
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