The Centers for Medicare & Medicaid Services (CMS) on April 27, 2023, finalized its annual notice of benefits and payment parameters for federal health care marketplaces and state-based marketplaces on the federal platform. The changes focus on maintaining affordable coverage, eliminating gaps in coverage, and increasing access to health care.
Essential Community Providers
CMS updated the essential community provider (ECP) requirements for qualified health plans (QHPs). CMS added two stand-alone ECP categories — mental health facilities and substance use disorder treatment centers — that both were previously included with Other ECP providers.
CMS added rural emergency hospitals to the Other ECP category and will require QHPs to contract with at least 35 percent of available federally qualified health centers in the plan’s service area and 35 percent of family planning providers.
Special Enrollment Periods
CMS will allow marketplaces the option of a special enrollment period (SEP) for individuals who are disenrolled from Medicaid or the Children’s Health Insurance Program (CHIP) based on income eligibility. State Medicaid agencies must provide a 90-day reconsideration window to allow former beneficiaries to provide the necessary information to reestablish their Medicaid or CHIP eligibility. The marketplace SEP will better align with this requirement and extend the SEP after loss of Medicaid or CHIP coverage from 60 to 90 days.
Further, CMS clarifies that only one person in a tax household applying for marketplace coverage needs to qualify for a SEP for the entire household to qualify. The agency also provides the option to marketplaces to allow mid-month coverage if an individual would lose minimum essential coverage.
Other Provisions
CMS also finalized provisions to:
- Allow marketplaces to modify their reenrollment hierarchy to prioritize reenrollment in silver plans with cost-sharing reductions (CSRs) over bronze plans without CSRs.
- Limit the number of nonstandardized plan options per issuer to four in plan year (PY) 2024 and two in PY 2025.
- Amend regulations to delay the application of the appointment wait time standards for QHPs until PY 2025.
- Allow door-to-door enrollment by navigators and assisters.
Contact Director of Policy Rob Nelb, MPH, at rnelb@essentialhospitals.org or 202.585.0127 with questions.
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