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CMS Finalizes 2021 Marketplace Rule, Letter to Issuers

The Centers for Medicare & Medicaid Services (CMS) May 7 finalized the Notice of Benefit and Payment Parameters for 2021 for the Affordable Care Act’s health insurance marketplaces and the letter to issuers for plans offered on federally facilitated marketplaces.

Details of Final Rule

The final rule updates regulatory and financial requirements for the marketplaces and insurance issuers, while supporting CMS’ goals to lower premiums and strengthen competition and choice for consumers seeking coverage through the marketplaces.

For 2021, CMS will maintain user fee rates charged to issuers offering plans on the federally facilitated marketplace and state-based marketplaces on the federal platform, to 3 percent and 2.5 percent per premium, respectively.

CMS also provides detailed options for how issuers can develop value-based insurance designs for qualified health plans (QHPs). Value-based QHPs would be a voluntary option for issuers, designed to provide consumers high-quality care at lower costs. CMS also finalized updates to provisions related to risk adjustment and risk-adjustment data validation programs, which ensure plans are not avoiding high-cost patients.

The rule finalized changes to the policy regarding treatment of drug manufacturer coupons and several reporting requirements. CMS did not finalize its proposal to implement an active re-enrollment process for consumers who have no premiums after application of tax credits due to overwhelming opposition from commenters.

Details of Letter

The final letter to issuers mirrors the payment notice final rule. CMS directs issuers to previous marketplace rulemaking for information about provisions the agency did not address in this rulemaking.

CMS did not propose any changes to network adequacy and essential community provider inclusion in QHP networks in the proposed rule or draft letter to issuers. These standards remain unchanged from 2018 health insurance marketplace rulemaking.

In addition the final rule and letter to issuers, CMS released these resources:

The final rule will be published in the Federal Register on May 14, with an effective date of July 13.

Contact Senior Director of Policy Erin O’Malley at eomalley@essentialhospitals.org or 202.585.0127 with questions.

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About the Author

Gontscharow is a senior policy analyst for America's Essential Hospitals.

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