What’s in the 2024 CMS final rule for the Marketplace?

Changes to Marketplace regulations for 2024 have been finalized by CMS, or the Centers for Medicare & Medicaid Services. A focus on a more streamlined market experience should result from the most prominent changes made to network regulations, essential community provider (ECP) categories, non-standardized plans, bronze to silver cross walking, and SEP tweaking for those affected by the Great Unwinding. But, a few other modifications are on the horizon, too.

Non-standardized plans and plan naming conventions

In plan year 2024, carriers will be limited per service area to offering four non-standardized health plans per network type, metal tier, and dental and/or vision benefit. This does not include catastrophic coverage. The inclusion of vision and dental in a plan will count separately towards the total of non-standardized plans a carrier can have. This number will be reduced to two in 2025. This new limit should work to reduce the number of poorly valued plans available to consumers.

But what if your plan is eliminated? Your carrier must offer you the same network in whatever plan you wind up with.

In addition, carriers with non-standardized quality health plans (QHPs) on the Marketplace are required to offer the standardized version of that QHP at each metal tier, network type, and dental and/or vision coverage inclusion. A standardized plan option will no longer be available for the non-expanded bronze metal tier.

QHPs naming conventions will also be altered.

New SEP for Medicaid unwinding

Marketplaces can now implement a new Special Enrollment Period for those losing Medicaid or Children’s Health Insurance Program (CHIP). This will allow consumers to have up to 60 days before and 90 days after the loss of coverage to select a Marketplace plan. More information about this SEP and other ways to support clients affected by the Medicaid Unwinding can be found here. Each state’s rules will be different, so make sure to brush up on the rules in your state.

Currently, if a beneficiary of Medicaid loses coverage before their coverage’s effective date, they could potentially have a gap in coverage. CMS amends this situation by allowing Marketplaces to flex coverage effective dates to close these gaps. Some states, like Michigan, are taking an alternative route. Instead, Michigan terminates Medicaid coverage at the end of each month, which allows the new coverage to begin as early as the first of the next month.. Again, each state will be different, so check in with your state’s policies.

Network regulations

All QHPs, including stand-alone dental plans (SADPs) and small business health option program (SHOP) plans, regardless of Marketplace type, must use a network of providers that complies with network adequacy and ECP regulations. This will negate the exception currently in place for plans that do not use a provider network. The only exception made for this rule will apply to areas with a shortage of Marketplace-contracted dental providers in the geographic area.

Two additional major ECP categories will be created: Mental Health Facilities and Substance Use Disorder Treatment Centers. A rural emergency hospitals category will be added to the Other ECP Category. These new categories, network rules, and the widening of ECP regulations across the board, should give those in underserved areas more access to more care.

Stand-alone dental plans

Two new rules have been carved out for SADPs. Stand-alone dental plans on or off Marketplace using age as a rating factor may only use the age an applicant is at the coverage effective date. SADPs must have a guaranteed rate for 2024.

Payments and income regulations          

Many changes in the finance area are planned for the Marketplace this year. First, those who failed to file income taxes for one year cannot get their Advance Premium Tax Credit (APTCs) revoked based on that transgression alone. Notices must be sent to consumers warning them of their potential loss of APTCs if they do not file income taxes; then, the consumer must fail to file income taxes again for a second year before the APTCs can be terminated. This gives administrators time to catch up on paperwork and should reduce the likelihood someone will be denied coverage despite having recently resolved any income tax issues.

The handling of income inconsistencies is also getting revamped. When an enrollee qualifies for APTCs, the Marketplace might make a request to the Internal Revenue Service (IRS) for documentation for proof of income purposes. That could become problematic for potential enrollees to get ahold of due to life changes like marriage or childbirth. Currently, enrollees get 90 days to provide proof of household income. If any income documentation is found inconsistent, enrollees get an automatic 60-day extension tacked on to that 90 days to provide further documentation.

Bronze to silver cross walking

Due to revamped thresholds, more enrollees than ever before are qualifying for cost-sharing reductions (CSRs) or APTCs, which can only be applied to silver plans. This creates an overlap between those who are currently in a bronze plan but would now qualify for CSRs if they had a silver plan instead of bronze. In order to assist affected consumers, CMS will automatically enroll consumers into a lower premium silver plan if applying those newly available cost sharing reductions creates a new, lower premium silver option. Network similarity must be taken into account when this process takes place.

This change should allow for even more Americans to save money in on health insurance, as they can not only apply those tax credits or cost

Wildcards: wait time changes, assisters, and risk adjustment models

A few loose ends wrap up this year’s changes. Providers will have one more plan year, then they will have to start reporting their ability to adhere to wait time standards. Assisters and agents are now able to go door-to-door to help consumers with enrollment, education, and health equity. And last but not least, adjustments have been made to risk adjustment models.

Streamlined and supportive

While some other changes are scheduled for the plan year 2025, most of these will be implemented starting on June 5.^. Overall, these changes should create a more intentional list of plans for consumers with networks that create higher standards for more people. Those on both the consumer and carrier ends who must submit additional paperwork get more time to do so, and more support has been provided for those that need it, whether it be assistance in choosing a plan or time to choose that plan.