Understanding the HHS 2023 Proposed Rule
Posted in Managed Care
Understanding the HHS 2023 Proposed Rule

The Department of Health and Human Services (HHS) released its Notice of Benefit and Payment Parameters for the 2023 Proposed Rule on January 5, 2022. Generally, the proposed rule aims to bolster the regulatory framework supporting the marketplace and expand access to health insurance coverage options. 

Specifically, HHS’ stated goals are “enhancing consumer experience, increasing consumer understanding, simplifying the plan selection process, combatting discriminatory benefit designs that disproportionately impact disadvantaged populations, and advancing health equity.” The following are key highlights and takeaways for health care organizations.

Enhancing Consumer Choice and Experience

First, the proposed rule looks to enhance consumer options and choice by both ensuring network adequacy and standardizing plan options in the Federally Facilitated Marketplace (FFM) and the State-based Marketplaces on the Federal Platform (SBM-FPs). 

To ensure network adequacy, the Centers for Medicare & Medicaid Services (CMS) will conduct reviews in all FFM states except those performing plan management functions that adhere to the more stringent federal standard and elect to perform their own reviews. Issuers in the FFM and SBM-FPs will be required to offer standardized plan options at every product network type, metal level and throughout every service area that they offer non-standardized options in plan year (PY) 2023.

CMS also aimed to enhance consumer experience by both prohibiting Qualified Health Plan (QHP) advertising and requiring the display of explanations for QHP recommendations on web broker websites. 

Removing Discrimination and Barriers to Care

In response to the Presidents Executive Order 13988, CMS will once again prohibit discrimination based on sexual orientation and gender identity. The essential health benefits nondiscrimination policy will also be adjusted to ensure that health plan designs (such as benefit designs, benefit limitations and plan coverage requirements) are based on clinical evidence rather than presumptive age, health conditions and sociodemographic factors.   

To further help populations that have historically faced barriers to access health care, CMS will scale back the special enrollment period verification to include only the special enrollment period for loss of minimum essential coverage. Additionally, CMS proposes to require QHP issuers to address health and health care disparities as a specific topic area within their quality improvement strategy standards beginning in PY2023.

Lastly, low-income and medically underserved consumers would potentially see improved access to health care in PY2023 and beyond because the rule proposes raising the Essential Community Provider threshold from 20 to 35 percent in each plan’s service area. 

Risk Adjustments and Lowering Premiums

Finally, the proposed rule would also make changes geared towards lowering premiums and strengthening markets. In order to do so, CMS is considering changing the risk adjustment process in two separate ways. 

First, risk adjustment models would be refined to improve prediction in the adult and child models for the lowest-risk enrollees, the highest-risk enrollees and partial-year enrollees, whose plan liabilities are under-predicted in the current models. Second, CMS proposes further refinements to the HHS Risk Adjustment Data Validation error rate calculation methodology beginning with the 2021 benefit year and beyond. 

CMS is also hoping to lower premiums by specifying those Quality Improvement Activity expenses that may be included for Medical Loss Ratio reporting and rebate calculation purposes as only those expenses that are directly related to activities that improve health care quality. 

The fact sheet released by CMS can be found here. 

  • James M. Reilly

    James Reilly provides legal guidance to clients in the healthcare industry. He ensures healthcare entities are able to deliver high quality services to their patients while complying with government agency regulations. He also ...

Our Health Law Ticker is a one-stop resource for everything new and noteworthy in healthcare law. We cover recent developments in healthcare legislation, healthcare reform, Medicare/Medicaid, managed care, litigation, regulatory compliance, HIPAA, privacy, peer review, medical staffs and general business operations for healthcare companies and licensed healthcare professionals.

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