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CMS Finalizes Standards To Strengthen ACA Marketplaces

The Centers for Medicare & Medicaid Services (CMS) has finalized new standards to strengthen and stabilize health insurance marketplaces under the Affordable Care Act.

In the Notice of Benefit and Payment Parameters for 2018, released Dec. 16, CMS finalized its proposal to continue the current methodology, which qualified health plans (QHPs) use to satisfy the minimum essential community provider (ECP) standard. QHPs must include at least 30 percent of all available ECPs in their service area to meet network adequacy requirements. The methodology counts multiple providers at a location as a single ECP. However, the agency will continue to collect data to inform a possible alternative calculation methodology that would credit QHP issuers for multiple ECP providers and practitioners at a single location.

In addition, CMS will consider changes to how hospital ECPs are counted for the 2019 benefit year and is seeking feedback on the best approach for measuring hospital participation. The agency also solicited feedback on how to indicate to consumers whether marketplace plans are part of a larger, integrated health system. In the final rule, CMS noted it will continue to work with stakeholders and collect data to determine alternative approaches.

Meanwhile, the agency finalized proposals aimed at stabilizing the price of coverage offered in the federally facilitated marketplaces by updating the risk adjustment methodology in QHPS, including by:

  • better estimating of the risk associated with enrollees who are not enrolled for a full year;
  • using prescription drug data to improve predictive risk adjustment models; and
  • establishing transfers that will better account for the risk of high-cost enrollees.

The final rule will be published in the Federal Register on Dec. 22. Provisions in the rule will go into effect 30 days after publication.

Contact Director of Policy Erin O’Malley at or 202.585.0127 with questions.


About the Author

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

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