Final NBPP 2024 released: Let's see what made the cut...and what didn't.

 

The Affordable Care Act includes a long list of codified instructions about what's required under the law. However, like any major piece of legislation, many of the specific details are left up to the agency responsible for implementing the law.

While the PPACA is itself a lengthy document, it would have to be several times longer yet in order to cover every conceivable detail involved in operating the ACA exchanges, Medicaid expansion and so forth. The major provisions of the ACA fall under the Department of Health & Human Services (HHS), and within that, the Centers for Medicare & Medicaid (CMS)

Every 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 proposed tweaks to some of the specifics of how the ACA is actually implemented for the following year.

Back in December, CMS released the proposed NBPP for 2024, which included a long list of tweaks & changes (some major, some minor) to how the ACA functions and is administered. I did a deep dive into the proposed changes, with five separate blog entries on the nuts & bolts of it:

• Part 1
• Part 2
• Part 3
• Part 4
• Part 5

Last week, CMS issued the final NBPP 2024 rule, and while much of it didn't change, some of it did, so let's take a look:

In the HHS Notice of Benefit and Payment Parameters for 2024 final rule released today, the Centers for Medicare & Medicaid Services (CMS) finalized standards for issuers and Marketplaces, as well as requirements for agents, brokers, web-brokers, and Assisters that help consumers with enrollment through Marketplaces that use the Federal platform. These changes further the Biden-Harris Administration’s goals of advancing health equity by addressing the health disparities that underlie our health system. The final policies build on the Affordable Care Act’s promise to expand access to quality, affordable health coverage and care by increasing access to health care services, simplifying choice and improving the plan selection process, making it easier to enroll in coverage, strengthening markets, and bolstering program integrity.

Increasing Access to Health Care Services

• Network Adequacy and Essential Community Providers

CMS finalizes revisions to the network adequacy and essential community provider (ECP) regulations to provide that, subject to the limited exception described below, all individual market qualified health plans (QHPs), including stand-alone dental plans (SADPs), and all Small Business Health Option Program (SHOP) plans, including SHOP SADPs, across all Marketplace-types must use a network of providers that complies with the network adequacy and ECP standards in those sections, and to remove the exception that these sections do not apply to plans that do not use a provider network.

CMS finalizes a limited exception to this requirement for certain SADP issuers that sell plans in areas where it is prohibitively difficult for the issuer to establish a network of dental providers. Specifically, under this exception, an area is considered “prohibitively difficult” for a SADP issuer to establish a network of dental providers based on attestations from State Departments of Insurance in states with at least 80% of their counties classified as Counties with Extreme Access Considerations that at least one of the following factors exists in the area of concern: a significant shortage of dental providers, a significant number of dental providers unwilling to contract with Marketplace issuers, or significant geographic limitations impacting consumer access to dental providers. Requiring all QHPs, except as indicated, to use a provider network will better ensure consumer access to a sufficient choice of providers and will guarantee consumers have access to information on the availability of in-network providers.

I don't think this "rural state exception" for stand-alone dental plans was included in the proposed version, but could be wrong.

Further, in response to public comments, CMS also finalizes amendments to the regulations to delay the application of the appointment wait time standards until plan year (PY) 2025. Accordingly, QHP issuers in the Federally Facilitated Marketplaces (FFMs) will have one additional plan year before being required to attest to meeting appointment wait time standards.

As CMS noted in the 2023 Payment Notice, specific guidelines for complying with appointment wait time standards will be released in later guidance. This will allow CMS additional time to develop specific guidelines for how issuers should collect the requisite data from providers, how the metrics should be interpreted, and for public comment on the proposed guidance. We are also aware of other HHS initiatives to define and implement appointment wait times standards for other program areas. The additional year delay will allow HHS to ensure that these wait time standards are implemented in a holistic, logical way across programs.

It looks like the expansion of the 10 minute drive / 5 mile distance rules have been bumped out another year and are now more vague, which isn't a good sign.

In addition, CMS finalizes changes to expand access to care for low-income and medically underserved consumers by establishing two additional major ECP categories for PY 2024 and beyond, 1) Mental Health Facilities and 2) Substance Use Disorder Treatment Centers, and adding rural emergency hospitals as a provider type in the Other ECP Category. Additionally, for PY 2024 and beyond, CMS will retain the overall 35% provider participation threshold, and also extend the 35% threshold to two major ECP categories: Federally Qualified Health Centers and Family Planning Providers. These changes will increase provider choice and access to care for low-income and medically underserved consumers.

This doesn't seem to have changed.

Simplifying Choice and Improving the Plan Selection Process

Standardized Plan Options

CMS finalizes several minor updates with respect to standardized plan options. In particular, CMS will no longer include a standardized plan option for the non-expanded bronze metal level. Accordingly, for PY 2024 and subsequent PYs, issuers offering QHPs through the FFMs and State-based Marketplaces on the Federal platform (SBM-FP) must offer standardized QHP options designed by CMS at every product network type, at every metal level except the non-expanded bronze level, and throughout every service area that they offer non-standardized QHP options. CMS believes maintaining the highest degree of continuity possible in designing these standardized plan options is critical to reduce the risk of disruption for consumers enrolled in these plans.

CMS is not finalizing its proposal that issuers of standardized plan options must (1) place all covered generic drugs in the standardized plan options’ generic drug cost-sharing tier, or the specialty drug tier if there is an appropriate and non-discriminatory basis, and (2) place all covered brand name drugs in either the standardized plan options’ preferred brand or non-preferred brand drug cost-sharing tiers, or the specialty drug cost-sharing tier if there is an appropriate and non-discriminatory basis.

This is because although CMS agrees that this proposal could potentially enhance predictability for consumers, comments regarding the importance of continuing to permit issuer flexibility in designing formularies to manage increasing costs, the changing nature of the relative costs of generic and brand name drugs, and the risk of decreased medication adherence that could arise from changing the tiering placement for particular prescription drugs has led CMS to determine that it should further investigate the potential impact of this proposal.

Non-Standardized Plan Option Limits

CMS finalizes a limit on the number of non-standardized plan options that issuers of QHPs can offer through Marketplaces on the Federal platform (including SBM-FPs) to four non-standardized plan options per product network type, metal level (excluding catastrophic plans), and inclusion of dental and/or vision benefit coverage, in any service area, for PY 2024 and two for PY 2025 and subsequent plan years.

Ugh. While I'm glad to see CMS tightening up on non-standardized plans, this is a huge step back from the proposed rule, which would have limited carriers to no more than two options per network type & metal level starting in 2024. Allowing four of them next year means that a carrier could potentially offer as many as 48 different plans apiece:

• 4 bronze HMOs, 4 bronze PPOs, 4 bronze EPOs
• 4 silver HMOs, 4 silver PPOs, 4 silver EPOs
• 4 gold HMOs, 4 gold PPOs, 4 gold EPOs
• 4 platinum HMOs, 4 platinum PPOs, 4 platinum EPOs

...which isn't much of a limit. Then again, most carriers aren't offering any Platinum plans these days, so I guess that would effectively mean a maximum of 36 plans per carrier, but that's still not much better.

The other possible standardization that CMS was considering was to allow as many plans as a carrier wanted, provided each one had a $1,000 or higher deductible gap between them ("meaningful difference"), but it looks like they're going with the max number of plan rule instead. Years ago my colleague David Anderson originally proposed either limiting plans to one per metal level/network type (up to 12 total) or a 5% variance in premium between each plan, which would parallel the 1K deductible gap distinction.

CMS is finalizing this limit due to the continuing trend of plan proliferation, which increases the risk of plan choice overload as well as the risk of suboptimal plan selection and unexpected financial harm for consumers. Specifically, the average number of plans available to consumers on the Marketplace has increased from 25.9 in PY 2019 to 113.7 in PY 2023. Such plan choice overload limits consumers’ ability to make a meaningful selection when comparing plan offerings.

Under the limit on the number of non-standardized plan options that issuers can offer (for both PY 2024 and PY 2025), CMS will permit additional flexibility specifically for plans with additional dental and/or vision benefit coverage. In the final rule, CMS clarifies the specific dental and/or vision benefit coverage a non-standardized plan option would need to include in order to qualify for this additional flexibility.

By modifying the proposed policy to increase the limit of non-standardized plan options that issuers can offer to four instead of two for PY 2024, and by modifying the proposed policy to also factor the inclusion of dental and/or vision benefit coverage into this limit, CMS estimates (based on PY 2023 enrollment and plan offering data) that the weighted average number of total plans (which includes both standardized and non-standardized plan options) available to each consumer will be reduced from approximately 113.7 in PY 2023 to 90.5 in PY 2024. As explained further in the final rule, CMS is unable to provide meaningful estimates for the impacts of the limit of two non-standardized plan options for PY 2025 and subsequent plan years due to PY 2024 plan offering and enrollment data limitations.

(Sigh) Again, 90 is better than 114 but not by much. It's still a coffee, coffee, coffee situation...

Similar to the approach taken with respect to standardized plan options in the 2023 Payment Notice and in this final rule, CMS will not apply this requirement to issuers in State-based Marketplaces (SBMs). Further, consistent with the approach taken with respect to standardized plan options in the 2023 Payment Notice and in this final rule, since SBM-FPs use the same platform as the FFMs, CMS will apply this requirement equally on FFMs and SBM-FPs. Finally, also in alignment with the approach taken with respect to standardized plan options in the 2023 Payment Notice as well as the approach taken in this final rule, this requirement would not apply to plans offered through the SHOPs or to SADPs.

Finally, CMS is not finalizing a meaningful difference standard since it believes that directly limiting the number of non-standardized plan options that issuers can offer would be a more effective and straightforward approach to reducing the risk of plan choice overload.

Hmmmm...I could argue otherwise on the last point, but whatever. It's frustrating that they aren't requiring SBMs to limit their offerings, although some of them (like California and Massachusetts) already require standardized plans anyway.

Stand-Alone Dental Plans (SADPs)

CMS finalizes changes to require issuers of SADPs, 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 PY 2024. This requirement will apply to Marketplace-certified SADPs, whether they are sold on- or off-Marketplace. We believe 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, will reduce consumer confusion and promote operational efficiency.

CMS also finalizes changes to require issuers of SADPs, as a condition of Marketplace certification, to submit guaranteed rates beginning with Marketplace certification for PY 2024. This requirement will apply to Marketplace-certified SADPs, whether they are sold on- or off-Marketplace. We believe this policy change will help reduce the risk of incorrect advance payments of the premium tax credit (APTC) calculation for the pediatric dental essential health benefit portion of premiums, thereby reducing the risk of consumer harm.

This looks identical to the proposed rule.

Re-enrollment Hierarchy

CMS finalizes changes to allow Marketplaces to modify their automatic re-enrollment hierarchies such that enrollees who are eligible for cost-sharing reductions (CSRs) and are currently enrolled in a bronze level QHP, and who would otherwise be automatically re-enrolled in a bronze-level QHP, are instead automatically re-enrolled in a silver-level QHP (with CSRs) in the same product with the same provider network and with a premium after the application of APTC that is lower or equivalent to the premium of the bronze level QHP into which the enrollee would have otherwise been re-enrolled, (referred to as the “bronze to silver crosswalk policy”). Marketplaces have the option to implement the bronze to silver crosswalk policy as soon as plan year 2024, and CMS will implement this policy in Marketplaces on the Federal platform for plan year 2024.

Furthermore, for enrollees whose current QHP or product will no longer be available in the coming year, CMS is also amending the Marketplace re-enrollment rules to require all Marketplaces (Marketplaces on the Federal platform and SBMs) to incorporate network similarity into the auto re-enrollment criteria. Marketplaces (including Marketplaces on the Federal platform and SBMs) must implement re-enrollment changes for enrollees whose QHP is no longer available beginning with the open enrollment period for PY 2024 coverage. As discussed in the final rule, we will implement this policy in PY 2024 for Exchanges on the Federal platform by incorporating plan network ID into the auto re-enrollment process, while continuing to take into account enrollees’ current year product. We will also work with issuers and State regulators to learn how we may improve methods to analyze and ensure network continuity in future years.

This seems to actually be stronger than the proposed version which only stated that they would allow SBMs to do this as opposed to requiring them to do so. Interesting.

UPDATE: Louise Norris is also pretty sure the network provision itself has been tightened up--apparently it used to say the cross-walked network has to be "similar" to the existing one; the final rule says it has to be "the same" as the prior network.

As I noted last December:

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.

Back to the final rule...

Establish Requirements for Qualified Health Plan and Plan Variant Marketing Names

CMS finalizes changes 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 policy 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.

CMS will 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.

This is also a big deal, since some QHPs have confusing or misleading names or branding. Again, as I noted earlier:

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.

Again, this appears to be identical to the proposed rule.

Making It Easier to Enroll in Coverage

Special Enrollment Periods

CMS finalizes that beginning January 1, 2024, Marketplaces have the option to implement a new special rule for consumers losing Medicaid or Children’s Health Insurance Program (CHIP) coverage that is also considered minimum essential coverage (MEC), under which consumers will have up to 90 days after their loss of Medicaid or CHIP coverage to select a plan for Marketplace coverage via a Special Enrollment Period (SEP). This change aligns the Medicaid or CHIP SEP period with the 90-day Medicaid or CHIP reconsideration period, which allows consumers the opportunity to have their eligibility for Medicaid or CHIP coverage reconsidered without having to resubmit a new application with their State Medicaid Agency.

Marketplaces will have the flexibility to decide whether to offer this special rule or not. SBMs will also be able to provide consumers losing Medicaid or CHIP coverage with more time to select a QHP, up to the number of days provided for during the applicable Medicaid or CHIP reconsideration period, if the State Medicaid Agency allows or provides a longer Medicaid or CHIP reconsideration. SBMs will also have the option to implement this special rule as soon as the final rule takes effect, instead of on January 1, 2024, if they so choose. CMS believes that this new special rule will help mitigate coverage gaps when consumers lose Medicaid or CHIP while allowing for a more seamless transition into Marketplace coverage.

No changes here that I can see. This is being done in response to the ongoing post-COVID emergency "Medicaid Unwinding" process.

CMS also finalizes changes to the current coverage effective date requirements so that Marketplaces have the option to offer earlier coverage effective dates for consumers attesting to a future loss of MEC which may avoid gaps in coverage, effective as of the effective date of the final rule. CMS believes that these changes will ensure qualifying individuals are able to seamlessly transition from other forms of coverage to Marketplace coverage as quickly as possible with minimal coverage gaps. For example, when a consumer attests between May 16 and June 30 that they will lose other MEC on July 15 and selects a plan on or before June 30, coverage will be effective on July 1. If that consumer selects a plan between July 1 and July 15, coverage would be effective as of August 1 and if they select a plan between July 16 and September 15 (60 days after their loss of coverage on July 15), coverage would be effective the first of the month after plan selection; if a plan selection is made in August, coverage will be effective on September 1 and if a plan selection is made in September, coverage will be effective on October 1.

This, too, appears to be identical to the proposed rule.

CMS also finalizes changes to the regulation related to the SEP for plan display errors to remove the burden on the consumer to demonstrate that the consumer has been influenced by a material error related to plan benefits, service area, cost-sharing, or premium . This change aligns the policy of the Marketplaces on the Federal platform with current SEP operations. Currently, the regulation requires the qualified individual or enrollee, or their dependent, to adequately demonstrate to the Marketplace that a material error related to plan benefits, service area, or premium influenced their decision to purchase a QHP through the Marketplace. However, we have found that consumers may benefit when other interested parties can demonstrate to the Marketplace that a material plan display error influenced the consumer’s enrollment in a QHP through the Marketplace. Thus, we are removing the burden currently placed on consumers to demonstrate to the Marketplace that a material plan display error influenced the consumer’s decision to purchase a QHP. We are also including cost-sharing in the list of plan display errors that may entitle enrollees to this SEP.

Good. No changes from the proposed rule.

Income Data Matching Issues

CMS finalizes changes to accept the household’s income attestation when the Marketplace requests tax return data from the Internal Revenue Service to verify attested projected annual household income but such data is not available. Such cases often occur when household composition changes across tax years (marriage, divorce, birth of a child) or if individuals were previously below the filing threshold. All individuals receiving APTC are required to file taxes and to reconcile those payments with final annual income. Additionally, CMS finalizes the requirement that enrollees with income inconsistencies will receive an automatic 60-day extension in addition to the 90 days currently provided to allow applicants sufficient time to provide documentation to verify household income. These changes will reduce administrative burden, increase access, and have a positive impact on health equity.

No changes from the proposed rule.

Allow Door-to-Door Enrollment by Navigators and Other Assisters

CMS finalizes a policy permitting Assisters[1] to conduct direct door-to-door enrollment assistance to increase consumer engagement and advance health equity. Assisters currently conduct direct outreach, education, and schedule follow-up appointments, but are prohibited from providing enrollment assistance upon an initial interaction at the consumers’ residence. The prohibition on direct enrollment assistance during the first contact burdens the consumer and Assisters and creates access barriers for consumers to receive timely enrollment assistance.

No changes that I can see.

Failure to File and Reconcile Process

CMS finalizes that, as of the effective date of the final rule, Marketplaces may not determine consumers ineligible for APTC due to having failed to file a Federal income tax return and reconcile their past APTC for only one tax year. Instead, Marketplaces will determine enrollees ineligible for APTC after a taxpayer has failed to file a Federal income tax return and reconcile their past APTC for two consecutive tax years.

Notwithstanding this regulation change, the current pause on operations related to failure to file and reconcile will continue until the IRS is able to notify HHS, and HHS is able to notify the Marketplace, that a tax filer has failed to file and reconcile, which is anticipated to be for plan year 2025 eligibility determinations.

This entire section seems new to me--it may have been part of the proposed rule but I don't recall seeing it.

CORRECTION: Louise Norris informs me that the 2-year non-filing provision was included in the proposed version after all, so no change here.

Under this change, Marketplaces on the Federal platform will continue to send notices to consumers for any year in which they have failed to reconcile APTC as an initial warning to inform and educate consumers that they need to file and reconcile or risk being determined ineligible for APTC if they fail to file and reconcile for a second consecutive tax year and CMS recommends that SBMs take similar action. CMS is making this change as a result of analysis indicating that data lags in reporting from the IRS likely cause inappropriate coverage loss. CMS believes this change will help consumers avoid gaps in coverage by increasing retention in Marketplaces and will also help protect consumers from accruing large tax liabilities over multiple years. These changes will allow Marketplaces to maintain program integrity by denying APTC to consumers who have, over the course of two years, been given notification of their obligation to file and reconcile and failed to do so. This rule does not change the requirement for consumers receiving APTC to file taxes and reconcile their tax credits received.

I'm guessing the "data lags" referenced here got particularly bad during the COVID-era IRS backlog, but I presume it's a problem in other years as well.

Strengthening Markets

FFM and SBM-FP User Fees

For the 2024 benefit year, CMS is finalizing a user fee rate of 2.2% of premium for QHPs sold on the FFMs, and a user fee rate of 1.8% of premium for QHPs sold on the SBM-FPs. We anticipate these user fee rate decreases may exert downward pressure on insurance premiums for consumers.

Wow...they originally proposed reducing the User Fee from 2.75% to 2.5% and from 2.25% to 2.0% respectively. By reducing both fees even further (2.2% and 1.8%), they've taken away a major reason why some states have moved from the federal ACA exchange onto their own state-based platforms.

On average, these reductions will also reduce premiums by roughly $40/year per enrollee on states hosted via HealthCare.Gov, give or take.

HHS-Operated Risk Adjustment Program

For the 2024 benefit year risk adjustment models, CMS finalizes the use of 2018, 2019, and 2020 enrollee-level EDGE data for model recalibration for all coefficients, with no exceptions. Consistent with prior benefit model recalibrations, this involves the use of the three most recent consecutive years of enrollee-level EDGE data that were available for the applicable benefit year. The model coefficients for the 2024 benefit year listed in Tables 1 through 6 of the final rule are based on a blend of separately solved, equally weighted coefficients from the 2018, 2019, and 2020 benefit years of enrollee-level EDGE data for all coefficients. Using the three most recent consecutive years for recalibration of the risk adjustment models provides stability and minimizes volatility in changes to risk scores between benefit years due to differences in the dataset’s underlying populations, while reflecting the most recent years’ claims experience available. Additionally, CMS will continue to apply a market pricing adjustment to the plan liability associated with Hepatitis C drugs in the risk adjustment models for the 2024 benefit year.

CMS also finalizes, beginning with the 2023 benefit year, the proposal to collect and extract from issuers’ EDGE servers a new data element, a Qualified Small Employer Health Reimbursement Arrangement (QSEHRA) indicator, including the phased implementation approach, as well as to extract plan ID and rating area data elements issuers have submitted to their EDGE servers from certain benefit years prior to the 2021 benefit year. We also finalize a risk adjustment user fee for the 2024 benefit year of $0.21 per member per month.

Finally, we finalize repealing the ability of prior participant states to request a reduction in risk adjustment state transfers calculated by HHS under the state payment transfer formula in all state market risk pools starting with the 2025 benefit year. We also approve the request submitted by Alabama to reduce risk adjustment state transfers by 50 percent in its individual (including catastrophic and non-catastrophic risk pools) and small group markets for the 2024 benefit year.

HHS Risk Adjustment Data Validation

CMS finalizes further refinements to HHS Risk Adjustment Data Validation (HHS-RADV) to promote the goals of HHS-RADV and support the timely release of HHS-RADV results. Beginning with the 2021 benefit year of HHS-RADV, CMS finalizes no longer exempting exiting issuers from adjustments to risk scores and risk adjustment transfers when they are a negative error rate outlier in the applicable benefit year’s HHS-RADV results. Additionally, CMS finalizes changing the materiality threshold for random and targeted sampling for HHS-RADV participation from $15 million in total annual premiums Statewide to 30,000 total billable member months Statewide, beginning with the 2022 benefit year of HHS-RADV. CMS also finalizes shortening the window to confirm the findings of the Second Validation Audit (SVA) or file a discrepancy report, to within 15 calendar days of the notification by HHS, beginning with the 2022 benefit year of HHS-RADV. Further, CMS is discontinuing the use of the lifelong permanent condition list and the use of non-EDGE claims in HHS-RADV beginning with the 2022 benefit year of HHS-RADV, to better align HHS-RADV policies and the EDGE Server Business Rules used for EDGE data submissions.

As I noted last winter, I'm going to once again state that I don't know nearly enough about how ACA risk adjustment works to comment, so I'm just posting them as is.

Premium Adjustment Percentage and Payment Parameters

CMS issued the 2024 benefit year premium adjustment percentage, the maximum annual limitation on cost sharing, the reduced maximum annual limitation on cost sharing, and the required contribution percentage (payment parameters) in guidance on December 12, 2022,[2] consistent with policy finalized in the 2022 Payment Notice (86 FR 24140, 24237 through 24238).

I wrote an explainer about the Premium Adjustment Percentage Index (PAPI) in 2021. Basically, this is a complex formula which modifies how generous ACA exchange premium subsidies are, and which also impacts the maximum out-of-pocket expense ceiling for ACA enrollees each year. The PAPI increases or decreases slightly every year.

Bolstering Program Integrity

Establish Improper Payment Pre-Testing and Assessment for State Marketplaces

CMS finalizes the Improper Payment Pre-Testing and Assessment (IPPTA) program under which State Marketplaces will be required to participate in pre-audit activities that will prepare State Marketplaces for complying with the audits required under the Payment Integrity Information Act of 2019 (PIIA). CMS is extending the pre-testing and assessment period for each IPPTA group from one to two years, which will begin in either 2024 or 2025. The IPPTA will prepare State Marketplaces for the planned measurement of improper payments of APTC by testing processes and procedures that support HHS’s review of determinations of APTC made by State Marketplaces. IPPTA will also provide a mechanism for HHS and State Marketplaces to share information that will aid in developing a measurement process in future years.

Looks like this is the same as in the proposed rule.

Provisions Related to Agents, Brokers, or Web-brokers

CMS finalizes allowing HHS additional time to review evidence submitted by agents, brokers, or web-brokers to rebut allegations that led to suspension of their Marketplace agreement(s) or to request reconsideration of termination of their Marketplace agreement(s). HHS will have an additional 15 calendar days, or a total of up to 45 calendar days, to review evidence submitted by agents, brokers, or web-brokers to rebut allegations that led to the suspension of their Marketplace agreement(s) and notify the submitting agents, brokers, or web-brokers of HHS’ determination regarding the suspension of their Marketplace agreement(s). HHS will have an additional 30 calendar days, or a total of up to 60 calendar days, to review reconsideration requests and notify the submitting agents, brokers, or web-brokers of HHS’ reconsideration decision related to the termination of their Marketplace agreement(s). These extended review windows will be beneficial as the review process can involve parsing complex technical information and data, revisiting consumer complaints, and conducting outreach to consumers.

CMS also finalizes a requirement that agents, brokers, and web-brokers document that eligibility application information has been reviewed by and confirmed to be accurate by the consumer or the consumer’s authorized representative prior to application submission. This requirement will help with enforcement activities related to agents, brokers, and web-brokers and help expedite the adjudication of consumer complaints related to the provision of incorrect information on their eligibility applications. We are also finalizing the requirement that this documentation be retained by the agent, broker, or web-broker for a minimum 10 years and be produced upon request in response to monitoring, audit, and enforcement activities.

In addition, CMS finalizes a requirement that agents, brokers, or web-brokers document the receipt of consent from the consumer or the consumer’s authorized representative prior to providing assistance. This requirement will help with enforcement and help resolve disputes between enrolling entities and consumers, or between multiple enrolling entities. We are also finalizing the requirement that that this documentation be retained by the agent, broker, or web-broker for a minimum of 10 years and be produced upon request in response to monitoring, audit, and enforcement activities.

All of this looks pretty much identical to how it was worded in the proposed rule.

In short, the only significant changes from the proposed version of the NDPP I can see here are:

• Rural state exception for SADPs
• Delaying the network adequacy rules by another year (2025 vs. 2024)
• Major: Allowing up to 4 plans per metal/network type instead of 2 in 2024 for standardized plan section
• New (?): Allowing 2 years of non-filing vs. 1 year before APTC is lost
• Reducing the user fees more than originally proposed
• Making the re-enrollment network similarity rule mandatory instead of optional

Otherwise I think it's pretty much the same.