On April 28, the Centers for Medicare & Medicaid Services (CMS) finalized the 2023 Notice of Benefit and Payment Parameters for qualified health plans (QHPs) on the federal marketplace and state-based marketplaces that use the federal platform.
The rule establishes standards for issuers and marketplaces, as well as requirements for agents, brokers, web brokers, and issuers assisting consumers with enrollment through Affordable Care Act marketplaces that use the federal platform for the 2023 plan year (PY23).
Of interest to essential hospitals, the final rule:
- raises the essential community provider (ECP) threshold from 20 percent to 35 percent, although many QHPs already meet this threshold. The rule only requires the QHP to contract with one ECP per category;
- resumes federal reviews of network adequacy and adds emergency medicine to the review for time and distance standards; and
- requires essential health benefits be based on clinical evidence.
Beginning in PY24, CMS will evaluate QHPs for compliance with wait time standards, a measure the association opposed in comments to the agency. Further, the rule does not explicitly prohibit discrimination on the basis of sexual orientation and gender identity. The Department of Health and Human Services states that it is developing a proposed rule to prohibit discrimination based on sex under section 1557 of the Affordable Care Act. Future marketplace rulemaking will align with this rule.
Contact Senior Director of Policy Erin O’Malley at eomalley@essentialhospitals.org or 202.585.0127 with questions.
