NBPP 2024 Part 3: Dental Plans, Re-enrollment Hierarchy & QHP Marketing Names

The ACA includes a long list of codified instructions about what's required under the law, but many of the specific details are left up to the agency responsible for implementing it since the legal text itself can't possibly cover every conceivable detail involved. The major provisions of the ACA fall under the Department of Health & Human Services (HHS), and within that, the Centers for Medicare & Medicaid (CMS).

Each year, CMS issues a long, wonky document called the Notice of Benefit & Payment Parameters (NBPP) for the Affordable Care Act. This is basically a list of tweaks to some of the specifics of how the ACA is actually implemented.

Yesterday CMS released their proposed 2024 NBPP, which includes some important changes which, if included in the final version, will go into effect starting next fall (for calendar year 2024). The full proposed 2024 NBPP is actually 370 pages long; yesterday I posted the press release & Fact Sheet. Today I'm breaking it down into smaller chunks since there's a lot to talk about here:

Stand-Alone Dental Plans (SADPs)

CMS proposes to require SADP issuers, as a condition of Marketplace certification, to use age on effective date as the sole method to calculate an enrollee’s age for rating and eligibility purposes beginning with Marketplace certification for PY2024. CMS proposes that this requirement apply to Marketplace-certified SADPs, whether they are sold on- or off-Marketplace. Requiring SADPs to use the age on effective date methodology to calculate an enrollee’s age as a condition of QHP certification, and consequently removing the less commonly used and more complex age calculation methods, would reduce consumer confusion and promote operational efficiency.

CMS also proposes to require issuers of SADPs, as a condition of Marketplace certification, to submit guaranteed rates beginning with Marketplace certification for PY2024. CMS proposes that this requirement apply to Marketplace-certified SADPs, whether they are sold on- or off-Marketplace. This policy change would help reduce the risk of incorrect advance payments of the premium tax credit (APTC) calculation for the pediatric dental essential health benefit (EHB) portion of premiums, thereby reducing the risk of consumer harm.

I don't write about stand-alone dental plans very often. They're called "stand-alone" to distinguish them from some major medical qualified health plans (QHPs) which include dental coverage baked in. Around 2.27 million people selected SADPs during the 2022 Open Enrollment Period, and it sounds like CMS has been pretty lax about regulating them up until now, so they're cracking down on a few key elements.

Re-enrollment Hierarchy

CMS proposes to allow Marketplaces, beginning for PY2024, to modify their automatic re-enrollment hierarchies such that enrollees who are eligible for cost-sharing reductions (CSRs) and who would otherwise be automatically re-enrolled in a bronze-level QHP without CSRs, to instead be automatically re-enrolled in a silver-level QHP (with CSRs) in the same product with a lower or equivalent premium, provided that certain conditions are met.

Furthermore, we propose to amend the Marketplace re-enrollment hierarchy to allow all Marketplaces (Marketplaces on the Federal platform and SBMs) to ensure enrollees whose QHPs are no longer available to them and enrollees who would be re-enrolled into a silver-level QHP in order to receive income-based CSRs are re-enrolled into plans with the most similar network to the plan they had in the previous year, provided that certain conditions are met. We propose that Marketplaces (including Marketplaces on the Federal platform and SBMs) would implement this option beginning with the open enrollment period for plan year 2024 coverage, if operationally feasible, and if not then beginning with the open enrollment period for PY2025 coverage.

THIS IS HUGE. Right now, a current ACA exchange enrollee who takes no action whatsoever will be automatically re-enrolled into their existing policy for another year. If the exact same plan isn't available (due to being discontinued or because the carrier pulls out of their area) and they still take no action themselves, they're automatically "mapped" over to a different plan which is as close as possible to the one they're currently enrolled in.

"As close as possible" currently means that if, for instance, they're currently enrolled in a Silver HMO from Blue Cross Blue Shield of Michigan, they'll be mapped to a different Silver BCBSM HMO which should have the same provider network and so forth. If no other Silver BCBSM HMOs are available they have to make a choice on which plan to "map" you to instead. This isn't always so easy since some people are dead set on sticking with the same network, while others only trust a certain carrier brand and the bottom line premium price is the most important to others, and so on.

As Louise Norris explains:

For cases where an existing plan won’t be available in the coming year, HHS implemented a hierarchy in 2015 for determining what plan would be considered “most similar” to an enrollee’s current plan. HHS noted that the insurance carriers (as opposed to state regulators or the exchanges) are uniquely qualified to determine which plan is most similar to a plan that will no longer be available.

When a plan must be replaced, the carrier submits a “crosswalk” designation to the exchange, indicating which plan should be substituted during the auto-renewal process. The exchange uses that data to map current enrollees onto plans for the coming year, assuming the enrollees don’t return to the exchange to actively select their own plan.

Starting with 2016 coverage, it became increasingly popular for carriers to eliminate PPO plans in favor of HMOs, which allow carriers more control over costs...

For 2017, and again for 2018, we saw a not-insignificant number of carriers leaving the exchanges altogether. Obviously, all of the impacted enrollees had the option to return to the exchange during open enrollment to pick a new plan. But not everyone in that situation will do so. How does auto-renewal work in that situation?

For 2015 and 2016 coverage, HHS guidelines prevented the exchange from mapping enrollees to a plan offered by a different carrier. So if your health insurance carrier was exiting the exchange or pulling out of the individual market altogether – as was the case with 12 CO-OPs at the end of 2015 – the exchange generally couldn’t automatically re-enroll you in a similar plan from a different carrier.

As you can see, this gets pretty tricky. But there's another problem as well:

It’s possible that the mapped plan could have a higher premium, despite the fact that it will be the plan deemed “most similar” to what you’ve got now. Overall average rate changes have been much smaller in the last few years than they were in 2017 and 2018, but the rate changes for specific plans vary quite a bit from one to another, and this could be the case for the plan that your insurer or the exchange maps for you.

Because the cost of cost-sharing reductions has been added to silver plan rates in most states, premium subsidies are generally much larger than they were prior to 2018. This is resulting in free bronze plans in some areas, and gold plans that are less expensive than silver plans in some areas. Because of the sharp variation in premiums by metal level, it’s strongly recommended that people return to the exchange to select their own plan during open enrollment (or during a special enrollment period triggered by the impending loss of other coverage) regardless of whether their current plan will continue to be available.

The other problem is that a lot of lower-income people are enrolled in Bronze ACA plans even though they'd save a lot of money on deductibles and co-pays by switching to a high-CSR Silver plan instead. Until now, CMS has been pretty reluctant to second-guess enrollees on this issue even when it's blatantly obvious that they're spending far more than they need to for what's often the exact same provider network and carrier.

In the 2024 NBPP, CMS is proposing to finally go ahead and upgrade this population as long as it's to the enrollee's benefit to do so.

If this goes through, it should dramatically increase enrollment in high-CSR Silver plans while reducing enrollment in high-deductible Bronze plans accordingly, although it won't show up in the enrollment data for over another year.

On a related note, Adrianna McIntyre discovered that in future years CMS is at least considering automatically enrolling people in a zero-premium policy if they're eligible for one under certain circumstances:

HHS also seeks broad comment on alternative auto-enrollment policies that we should consider in future years. For example, we are curious about interested parties’ thoughts on an auto-enrollment policy under which consumers who have entered delinquency on their QHP premiums would be auto-enrolled into QHPs with no net premium after application of APTC (referred to as zero-dollar plans). In accordance with §§ 155.430(b)(2)(ii) and 156.270, a QHP/SADP may terminate an enrollee’s coverage for non-payment of premiums, subject to certain conditions. Specifically, § 156.270(d) requires issuers to observe a three-consecutivemonth grace period before terminating coverage for those enrollees who are eligible for, and have elected to receive, APTC and who, upon failing to timely pay their premiums, are receiving APTC. Research suggests that even small net premiums can significantly decrease enrollment and that this could be because paying even a small premium requires enrollees to take additional action.

In fact, I know all four of sources cited for that research:

173 Fiedler, M., & McIntyre, A. (2022, September 13). Tweaking the marketplace enrollment process could magnify effects of larger premium tax credits. Brookings.

174 Drake, C., Cai, S., Anderson, D., and Sacks, D. (2021, October 22). Financial Transaction Costs Reduce Benefit Take-Up: Evidence from Zero-Premium Health Plans in Colorado. SSRN.

Establish Requirements for Qualified Health Plan and Plan Variant Marketing Names

CMS proposes to require that QHP plan and plan variant marketing names include correct information, without omission of material fact, and do not include content that is misleading. This proposal will help consumers applying for coverage to understand references to benefit information in plan and plan variant marketing names, and to use this information to make an informed plan selection.

If finalized as proposed, CMS would review plan and plan variant marketing names during the annual QHP certification process in close collaboration with State regulators in States with Marketplaces on the Federal platform.

Here's some of the examples they cite regarding misleading plan marketing names by some carriers:

• Cost-sharing amounts that do not specify limitations the plan or plan variation includes, such as whether the cost-sharing amount is only available for drugs in a certain prescription drug category/tier, providers in a specific network or tier, or for a certain number of provider visits following which a higher cost-sharing amount will apply;

• Dollar amounts that do not specify what they refer to (for example, deductible, maximum out-of-pocket, or something else), whether they apply only to medical, drug, or another type of benefit, or whether, in cases of deductible or maximum out-of-pocket amounts, they apply to an individual or a family;

• Benefits, such as adult dental care, that are listed in a plan or plan variation marketing name to indicate that they are covered, but that plan documents indicate are not covered;

• Reference(s) to health savings accounts (HSAs) in marketing names of plans or plan CMS-9899-P 244 variations that do not permit enrollees to set up an HSA.

Here in Oakland County, Michigan, there's a policy from Priority Health called "MyPriority Standard Bronze 7500 - Ascension St. John Providence Network." Now, that's quite a mouthful, and in this case the "Bronze 7500" seems to accurately refer to a Bronze plan with a $7,500 individual deductible, and presumably the provider network is Ascension / St. John Providence...all of which is fine.

But what if Priority Health had decided to call this the "Bronze 4000" plan instead of "Bronze 7500," or decided to throw "HSA" into the plan name for the hell of it? The 4000 wouldn't have any meaning, nor would "HSA," but it would fool some people into assuming it had a $4,000 deductible and a Health Savings Account if they didn't read more carefully. I think that's the sort of thing they're talking about here.