This month, the Departments of Health and Human Services (HHS) published the final Notice of Benefit and Payment Parameters (NBPP) for 2021. This annual rule governs health insurance plans and health insurance marketplaces, and insurers depend on its regulations to set up its plans for the following year, according to NASHP.
The rule came out the latest it ever has due to the COVID-19 pandemic. HHS, therefore, pushed back the implementations of some requirements in the rule until 2022, including some changes related to special enrollment periods.
This piece highlights the major changes, as outlined directly by the Centers for Medicare and Medicaid Services (CMS).
• Offering a value-based qualified health plan will be voluntary for issuers, and these plans will not be preferentially displayed on HealthCare.gov.
• Issuers will be permitted, not required, to count toward the annual limitation on cost sharing amounts paid toward reducing out-of-pocked costs using any form of direct support offered by drug manufacturers to enrollees for specific prescription drugs.
• Issuers are required to deduct from incurred claims any price concessions received and retained by the issuer, and any prescription drug rebates and other price concessions received and retained by the entity providing pharmacy benefit management services to the issuer beginning with the 2022 Medical Loss Ratio reporting year.
• Issuers must report prescription drug rebates and other price concessions received and retained by an entity providing pharmacy benefit management services to the issuer as non-claim costs.
• Issuers can report specific wellness incentives as quality improvement activities in the individual market for MLR reporting and calculation purposes.
• Beginning with plan year 2021, states must annually notify HHS in specific form and manner of any state-required benefits applicable to qualified health plans in the individual and/or small group market that are in addition to essential health benefits. If not done so by deadline, HHS will identify which state-required benefits are in addition to EHB for the applicable plan year.
• HHS will require exchanges to apply plan category limitations to dependents who are currently enrolled in Exchange coverage, and whose non-dependent household member qualifies for a special enrollment period to newly enroll in coverage with them.
• HHS will not take enforcement action against exchanges that do not perform random sampling as required by administrative law when the exchange does not reasonably expect to obtain sufficient verification data for plan years 2020 and 2021.
• When exchanges process a voluntary termination for a dual enrollee, exchanges will not re-determine eligibility for APTC and cost-sharing reductions.
• When an exchange enrollee is identified as deceased through Death PDM, exchanges will not re-determine eligibility for APTC/CSRs and will terminate Exchange coverage back to the date of death.
• HHS will no longer incorporate MarketScan data in the recalibration process for the risk adjustment models beginning with the 2021 benefit year. Instead HHS will blend the three most recent years of available enrollee-level External Data Gathering Environment data. This will apply to the 2022 benefit year.
• HHS will not consider an issuer with fewer than 30 HCCs within an HCC failure rate group to be an outlier for that HCC failure rate group.
• The finalized 2021 maximum annual limitation on cost sharing is $8,550 for self-only coverage and $17,100 for other than self-only coverage.
• There is a 2021 reduced annual limitation on cost sharing for enrollees with incomes between 100 and 200 percent of the Federal Poverty Level (FPL) at $2,580 for self-only coverage and $5,700 for other than self-only coverage. The 2021 reduced annual limitation on cost sharing for enrollees with incomes between 200 and 250 percent FPL is $6,800 for self-only coverage and $13,600 for other than self-only coverage.
• The require contribution percentage for 2021 increased to 8.27392.
• Non-Federal governmental plan sponsors that offer excepted benefit HRAs must provide a notice that is consistent with the content of summary plan descriptions required under the Employee Retirement Income Security Act of 1974.
• State exchanges that operate their own eligibility and enrollment platforms can display the quality rating information provided by HHS or can display quality rating information with certain state-specific customizations of the quality rating information provided by HHS.
• Enrollees whose requests for termination of their coverage were not implemented due to an Exchange technical error to terminate their coverage retroactive to the date the enrollee had preciously requested to end his/her coverage, or retroactive to another appropriate date identified in Exchange regulations.
• Beginning in 2022, Exchange enrollees and their dependents who are enrolled in silver plans become newly ineligible for cost-sharing reductions can change to a QHP one metal level higher or lower if they choose.
• HHS will shorten the time between the date a consumer selects a plan through certain special enrollment periods and the effective date of that plan.
• HHS has reverted to a single retroactive effective date and binder payment rule that provides consumers who have an SEP with a retroactive effective date the option to pay one month’s premium and only receive prospective coverage.
• Individuals and their dependents who are provided with a qualified small employer health reimbursement arrangement with a non-calendar year plan year can qualify for the existing special enrollment period for individuals enrolled in any non-calendar year group health plan or individual health insurance coverage, based on the last day of their plan year.