The Centers for Medicare and Medicaid Services (CMS) has published its annual proposed changes to benefit 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 is updating essential community provider (ECP) requirements for qualified health plans (QHPs). For an issuer to provide a QHP on a health care marketplace, they must include 35 percent of available ECPs in-network and are only required to contract with one provider per category. CMS is adding two stand-alone categories — mental health facilities and substance use disorder treatment centers — that both were previously included with other ECP providers. The proposed ECP categories are:
- Federally qualified health centers (FQHCs).
- Ryan White Program providers.
- Family planning providers.
- Indian health care providers.
- Inpatient hospitals.
- Substance use disorder treatment centers.
- Mental health facilities.
- Other ECP providers.
Further, CMS proposes to add rural emergency hospitals to the Other ECP category. CMS also proposes to require QHPs to contract with at least 35 percent of available FQHCs in the plan’s service area and 35 percent of Family Planning Providers.
Special Enrollment Periods
CMS proposes to 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 would better align with this requirement and would 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 must 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 proposes to:
- Establish a new automatic reenrollment hierarchy that would prioritize reenrollment in silver plans with cost-sharing reductions (CSRs) over bronze plans without CSRs.
- Simplify plan options for consumers by limiting the number of nonstandardized plan options by issuers.
- Allow door-to-door enrollment by navigators and assisters, who currently only can conduct outreach and education door-to-door.
Contact Director of Policy Rob Nelb, MPH, at rnelb@essentialhospitals.org or 202.585.0127 with questions.
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