Thread by @charles_gaba

📣 Yesterday CMS released #NBPP2023! This is a Big Deal in healthcare wonkery circles.

The NBPP is the rulebook for various changes in how the #ACA will be administered in the upcoming year. Each year there's various tweaks...some major, some minor. 1/

The document itself is several hundred pages, but it boils down to a dozen or so major provisions (plus various minor ones).

Some of these get *really* wonky & over my head, but most aren't too in the weeds. I've broken them out into several posts. 2/

First up: STANDARDIZED PLANS!

A few years ago, there was a risk of "bare counties" where there weren't ANY insurance carriers offering ACA policies. Today, it's the opposite: The market is often saturated with *hundreds* of near-identical plans. 3/

acasignups.net/22/04/28/nbpp-…

The solution to this, as a few states have discovered, is to mandate *standardized plans* where all plans at the same metal level (bronze, silver, gold, platinum) have identical deductibles, co-pays etc. This lets enrollees compare them on premium, network & quality. 4/

CMS dipped its toe into the "standardized plan" pool 5 years ago, but only partially: Carriers COULD offer them but weren't required to. Starting in 2023, they'll HAVE to.

One catch: They'll still be allowed to ALSO offer NON-standard plans as well. 5/

acasignups.net/22/04/28/nbpp-…

The risk of allowing standardized AND non-standardized plans is that it could add *more* confusion to the marketplace instead of reducing it. Still, requiring them to be included is a first step; hopefully ALL plans will be standardized by 2024. 6/

Next: NETWORK ADEQUACY!

One of the biggest complaints about ACA plans is that many of them only include "skinny networks" of healthcare providers. It's not much use to have an inexpensive plan that covers nearly all of your medical costs if the nearest doctor is 3 hours away. 7/

The ACA itself includes guidance on "adequate" provider network requirements, but they've always been kind of vaguely defined. Starting in 2023, CMS is cracking down on this with specific requirements. 8/

acasignups.net/22/04/28/nbpp-…

For instance, starting in 2023, plans will have to include a primary care provider within 10 minutes and 5 miles for enrollees in a large metro county.

Starting in 2024, they'll have to ensure that enrollees can get a primary care appointment within 15 days of the request. 9/

If a carrier can't meet the various requirements, they'll have to submit a justification to explain why they can't, and so forth.

How will CMS enforce network rules? Beats me, although as @cdrake219 noted, they already do so for Medicare Advantage plans, so (shrug)... 10/

One likely consequence of the new network adequacy rules is that some carriers which specialize in "skinny networks" may drop out of the ACA markets. This isn't necessarily a terrible thing (again, see the "market saturation" issue above). We'll see how it goes. 11/

NEXT: Better Actuarial Value rules!

ACA plans are grouped as "bronze," "silver," "gold" or "platinum," which cover *roughly* 60%, 70%, 80% or 90% of avg. enrollee medical expenses.

Those are *aggregate* averages, however; it doesn't mean your *specific* expenses. 12/

Since it's impossible to cover PRECISELY 70% (or 80%, etc) of a group of people's expenses ahead of time, insurers are given some wiggle room...+/- a few percent.

If that +/- is too wide, though, it makes it difficult to distinguish between levels. 13/

acasignups.net/22/04/28/nbpp-…

The #NBPP2023 tightens up on the +/- range (called "AV de Minimis") so that Bronze is Bronze, Silver is Silver and so forth.

This has the added indirect benefit of making ACA subsidies a bit more generous, which is a Good Thing®. 14/

NEXT: Improved Nondiscrimination Rules!

This covers a wide array of nondiscrimination policies, but the primary focus is on the population which is being subjected to the most heated attacks right now: The LGBTQI+ community: acasignups.net/22/04/28/nbpp-…

Next: Starting in 2023, at least 35% of healthcare providers in ACA insurance carrier networks will have to be Essential Community Providers (ECPs). This is up from the current 20% threshold.

ECPs work with low-income/underserved communities.

acasignups.net/22/04/28/nbpp-…

Next: CMS is easing up on Special Enrollment Period eligibility verification.

Normally you can't enroll in ACA coverage outside of the Open Enrollment Period unless you have a Qualifying Life Experience like losing employer coverage, moving, having a kid, etc. 17/

When you have a QLE, you usually qualify for a 60-day Special Enrollment Period (SEP) to get covered in an ACA plan for the rest of the year.

For awhile, this was done mostly on the honor system. The Trump Admin cracked down heavily on this by requiring documentation. 18/

In man cases this could be a ROYAL pain in the ass & often discouraged fully eligible people from going through the hassle.

Then the COVID pandemic hit and 10 million+ lost their jobs within a matter of weeks. acasignups.net/22/04/29/were-…

The COVID pandemic completely threw the conventional wisdom about "adverse selection" and "gaming the system" into chaos. Also, some studies found that strict SEP verification rules may actually *backfire* because *younger, healthier* enrollees are *less* likely to bother. 20/

The idea behind SEP verification is to prevent someone from "gaming the system" by waiting until they're really sick to get covered, then "faking" SEP eligibility to get in during the off-season. If young/healthy folks are turned off, that makes the problem WORSE. 21/

In response, CMS will still be requiring verification for many SEP enrollees but will be backing off on some types. 22/
acasignups.net/22/04/28/nbpp-…

These next three are things I honestly know very little about: Quality Improvement Strategy (QIS) standards, Risk Adjustment and Risk Adjustment Data validation.

I'll just link to the text of the fact sheet for these: 23/
acasignups.net/22/04/28/nbpp-…

Next: Aye, PAPI!!

The Premium Adjustment Percentage Index is a wonky formula which modifies ACA subsidy generosity & maximum out-of-pocket expenses. the PAPI changes up or down slightly year to year.

Personally, I hate it & think they should scrap it.

acasignups.net/22/04/28/clone…

Next: Medical Loss Ratio (MLR) crackdown!

To discourage price gouging by insurance carriers, the ACA mandates that at least 80% of their premium revenue has to be spent on actual medical care.

Anything under 80% has to be rebated to the enrollees. 25/
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The MLR program has been successful--ACA policyholders have had BILLIONS of dollars paid back to them over the past decade.

However, insurers are always trying to play with the MLR rules by trying to count more expenses as "medical care" instead of "overhead". 26/

In response, CMS is cracking down on this sort of thing starting in 2023: 27/
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This next one actually came as a complete surprise to me, which is crazy since I've been writing about the ACA for 9 years now: APTC partial-month proration.

Basically, this deals with what happens if you terminate your ACA coverage part way through the month. 28/

ACA tax credits are applied at the beginning of the month, so if you terminate your policy mid-month, currently you may have to pay back the "excess" credits when you file your taxes the following spring.

#NBPP2023 addresses this problem. 29/

The last two items relate to 3rd party "web brokers," which are basically authorized private versions of HealthCare.Gov like Health Sherpa, W3LL, Stride Health and so on.

(disclosure: several of these have ads on my site) 30/

Sites like these will be required to explain why they highlight certain plans over others--ie, "recommended" plans, listing plans in a certain order, etc.

They'll also be prohibited from advertising or giving "preferred placement" to certain plans based on compensation. 31/

There's probably several other new/changed policies in the #NBPP2023 which I missed (@SabrinaCorlette has her own thread w/more tidbits), but I think this covers the vast majority of them. 32/

These changes, along w/the recent announcement of the #FamilyGlitch being closed, *should* make the 2023 Open Enrollment Period a lot better...with one major potential turd in the punchbowl which would overwhelm almost all of them: acasignups.net/22/04/25/new-s…

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