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CMS tackles provider availability, exchange regulations in proposed rule

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Dive Brief:

  • The CMS has proposed revised rules and regulations for insurers operating on Affordable Care Act marketplaces, including attempting to boost provider availability through revising network adequacy and essential community provider standards, according to the 2024 HHS Notice of Benefit and Payment Parameters proposed rule released Monday. 
  • The proposed rule requires that all marketplace plans must use providers that comply with network adequacy and essential provider standards, removing an exception that those regulations don’t apply to insurers who don’t use a provider network. It also requires insurers to include at least 35% of providers in any given market into their networks.
  • The proposed regulations come as ACA exchanges, spurred by financial incentives during the COVID-19 pandemic, reached record enrollment numbers this year.

Dive Insight:

The CMS has increasingly been aligning itself with health equity initiatives as the Biden administration heightens its healthcare oversight into social issues. Its proposed standards released Tuesday are an attempt to further the administration’s “goals of advancing health equity by addressing the health disparities that underlie our health system,” according to the agency.

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

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

In addition to boosting provider availability, the CMS is proposing to limit the number of non-standardized plan options that issuers can provide on exchanges and increase the availability of standardized plans. Standardized plans are required to standardize their deductibles, out-of-pocket maximum and cost-sharing for plans with the same coverage metals.

The standardized plans are an attempt to help consumers make plan choices, according to the CMS, given that 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.”

In the proposed rule, insurers would only be able to offer two non-standardized plans at each network type per metal level on federal marketplaces.

For example, a plan would be limited to offering two gold health maintenance organization and two gold preferred provider organization non-standardized plan options in any service area in 2024 and beyond, according to the CMS.

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

Enrollees who lose Medicaid or Children’s Health Insurance Program coverage beginning Jan. 1, 2024, will have 60 days before or 90 days after coverage ends to enroll in another Marketplace plan due to a special enrollment period. The proposed rule also allows marketplace plans to have the option of providing earlier coverage start dates for those anticipating a loss of health coverage who would otherwise experience a gap in coverage.

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