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CMS Proposes New Standards to Strengthen ACA Marketplaces

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

In the Notice of Benefit and Payment Parameters for 2018, released Sept. 6, CMS proposed to continue the current methodology that 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 its service area to meet network adequacy requirements. The current methodology counts multiple providers at a location as a single ECP. However, the agency noted that it is collecting data to inform and implement a methodology that would credit QHP issuers for multiple ECP providers and practitioners at a single location.

In addition, CMS said it will consider changes to the counting of hospital ECPs for the 2019 benefit year and seeks 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.

Last, the agency proposed to stabilize the price of coverage offered in the federally facilitated marketplaces by strengthening risk adjustment in QHPs. CMS proposed price stabilization through changes to the risk adjustment methodology, including:

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

Comments on the proposed rule are due Oct. 6.

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


About the Author

Matt Buechner is the policy and advocacy associate for America's Essential Hospitals.

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