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It’s a playbook for the year, really. When the new Notice of Benefit and Payment Parameters (NBPP) rules are announced, they serve as a federally mandated set of guidelines and benchmarks for Marketplace providers. Every industry operates with a rule book of standard practices. And for the benefits of everyone who engages in the exchanges, there are also usually a series of checks and balances regarding Essential Health Benefits and standards for individual and group health plans. The NBPP rules ensure there is a level playing field for all providers and protects the health, data, and privacy of individuals who leverage the platforms.

But here we are in one of the most bizarre years in recent memory. The COVID-19 pandemic has blown in a cloud of uncertainty over everything, from households to business sectors, for most of 2020. And because of the unprecedented impact on Americans, leaving more health and human services questions moving forward than answers, many health insurance providers are fumbling in the dark with moving forward. The NBPP rules rolled out later than usual this year, and those abiding by those rules and standards were forced to launch prior to their release.

The new rules have loosened the reins on a variety of previously outlined analytics, data reporting, and sampling requirements, in part to provide more time to providers to enact compliance. But what other side effects might there be with this extension? Will this reduction in regulatory and fiscal burdens be helpful to providers in the long run, and will there be implications for Americans shopping for health insurance in the exchanges? While predicting the future is nearly impossible, there are some notable takeaways from these new NBPP rules

The NBPP Rules Themselves Came Later than Usual

HHS (Department of Health and Human Services) first rolled out its suggestions for this year’s NBPP rules in early February, before the nationwide shelter in place orders. Usually, comments are open, and official announcements of standards come early in the year. But due to the nationwide setbacks, various shutdowns, and health consequences on individuals, this year’s NBPP rule came the latest it’s ever been released, May 7, 2020. The delay in announcing the regulations meant there were several providers that had to develop and launch their 2021 plans without the guidance and requirements of a playbook. And many made decisions based on anticipating COVID-19 impacts on healthcare costs and insurer needs as a result of the pandemic. This industry wide period of uncertainty led to the loosening of the reins and extensions on policy requirements.

A Series of Delayed Deadlines & Benchmarks

Approaching this year’s rules, HHS and CMS recognized the hardships and unpredictability the pandemic has had on providers. So, rules and timeframe deadlines for implementing changes have been relaxed and extended, several of them through 2022. The new compliance standards for medical loss ratio (MLR) policy changes and calculations, with regard to special enrollment periods, for example, have been pushed back to 2022. This extension is especially applicable to providers who need to qualify applicants for a life-changing event. It also means those individuals looking for coverage outside of normal open enrollment periods may have a reprieve of sorts for in qualifying for a SEP.

A Departure from Some Data Sampling

This recent rules announcement also called for a departure of data sampling, specifically MarketScan® data. Instead, HHS says it will compile data over the last three years of data to recalibrate its risk assessment process. Using the more recent three years will allow for a blending of pre-pandemic sampling and current data to create models for rules to come. HHS says it will use enrollee-level data provided by the traditional External Data Gathering Environment (EDGE) data for now and through the 2022 benefit year. Looking at actual claims, along with data from past years, should be helpful in making relevant guideline suggestions.

Permissions of Copay Accumulator Programs

Another concession that came with the new NPBB rule involves copay accumulator programs, a method for excluding discounted prescription platforms from deductible applications. CMS officials are expressly allowing certain health insurance plans to use these programs and to make the decision whether or not to enable pharmaceutical-based or cost-sharing prescription plans to count towards an individual’s copay. This is an implication that can be favorable to health plans and providers but could be concerning at the individual level.

These out-of-pocket protection programs can offer much-needed prescription savings right now, especially when household finances are tight. But discounting those expenses from calculating towards the insurance plan’s annual deductible could sting a little. Good RX, a prescription savings company, is suggesting that nearly half of Americans are enrolled in high deductible plans through their employers right now. Thousands are still unemployed and struggling to stay afloat financially. And almost half of the enacted commercial plans have independent deductibles for prescriptions. So, while the latest rule authorizes companies to make decisions about copay accumulator programs, Americans may be facing more out-of-pocket costs in the long run.

The 2021 NBPP Rule does say these copay accumulator program determinations apply to plans sold on the Affordable Care Act exchanges, along with any individual and group plans not already grandfathered. States can, however, mandate different requirements, and some have. West Virginia, Virginia, Arizona, and Illinois have already imposed new laws that ban PBMs and insurance providers from using copay accumulator programs.

As we stare down the remaining few weeks of 2020, it’s clear we’re all hoping for a better 2021. And the new NBPP rules have widened the parameters in an effort to accommodate plan providers and Americans alike. There may be a return to mandates for 2022, many already set in motion. And there are more than likely going to be even more suggested changes as the pandemic continues to affect how people buy and need healthcare.

As the trends and guidelines continue to change, you may need a partner to help develop a data and platform strategy. Softheon is here to help you navigate this new normal and make sense of the new NBPP rules, requirement extensions, and latest benchmarks.