Stakeholder Perspectives and Feedback on Health Equity in the 2023 Notice of Benefit and Payment Parameters

In January, CMS issued its proposed annual Notice of Benefits and Payment Parameters (NBPP), which updates regulations governing the Affordable Care Act’s (ACA) marketplaces. CMS requested and received public comments on the proposed rule, and researchers at CHIR reviewed and summarized a sample of those comments from consumer advocates, insurers and brokers, and state insurance departments and marketplaces. A summary of the rule, including the request for input on health equity initiatives, can be found here. The notice of proposed rulemaking also requested feedback from stakeholders on ways for CMS to advance health equity. This blog summarizes feedback from the following representatives of consumer advocates, insurers, and state agencies:

Consumer Advocates

Insurers

State Departments of Insurance (DOI) and Marketplaces

In its proposed rule, CMS requested public comment on the following issues:

Health Equity Accreditation Requirements for Marketplace Insurers

The National Committee for Quality Assurance (NCQA) offers a health equity accreditation to insurers; CMS asked stakeholders to provide feedback on whether insurers on ACA marketplaces should be required to obtain this or similar accreditation.

Consumer advocates and state entities voiced some support for this requirement, though some called for more specific standards to advance equity for certain groups, such as people with disabilities. While some states already require NCQA health equity accreditation (e.g., Pennsylvania for Medicaid Managed Care Organizations and California for marketplace plans in 2024), the Pennsylvania DOI recommended focusing “less on the specific accreditation entity and more on the rigorous equity standards,” noting that doing so would allow states to consider comparable accreditations organizations other than NCQA. This sentiment was echoed by the NAIC, who encouraged CMS to allow state flexibility to recognize other forms of accreditation.

Insurers largely opposed a health equity accreditation requirement. Because the NCQA program is fairly new, insurers argued that the methods are unproven and potentially unreliable, suggesting data standards must be improved before requiring this (or a comparable) accreditation. Cigna pointed to the “significant operational work” involved in obtaining this accreditation to participate in California’s marketplace and opposed adopting a similar requirement on a national scale in the immediate future. In place of requiring this accreditation, some insurers argued instead for prominently displaying the accreditation of those who voluntarily obtained it on the marketplace plan shopping features.

Ensuring the Data Collected Promotes Health Equity

CMS asked stakeholders for guidance on what specific data points could be collected to advance health equity.

Most of the stakeholders in our sample stressed the importance of collecting data on key demographic characteristics such as race, ethnicity, language, sexual orientation, gender identity, and disability status. Many insurers also encouraged the collection of patient-reported health outcomes and hospital readmissions. Some stakeholders also urged targeted data collection efforts focused on key health outcomes. For example, NPWF argued that CMS should require insurers to report more robust and accurate data on the most common causes of maternal morbidity among Black mothers, emphasizing that this data could be used to help reduce fatalities and improve early diagnosis and treatment. BCBSA listed preventive service utilization rates and data on morbidity, mortality, and readmissions as important sources of information on enrollees’ health outcomes. Anthem further noted that investments in data exchange standards and infrastructure could help streamline eligibility determinations and enrollment of individuals and families in other programs, such as SNAP.

Stakeholders also discussed the best ways for CMS to assess enrollees’ access to culturally competent care. Insurers such as Anthem and BCBSA generally supported the collection of robust demographic data on plans’ in-network providers. BCBSA further called for broader government investments in pipeline programs to improve the diversity of the health care workforce, as well as incentives for providers to hire and retain “culturally humble” clinicians, particularly those who are from the communities they are hired to serve. Consumer advocates and state agencies generally echoed these sentiments.

Several stakeholders emphasized that providers themselves can help improve health equity data collection, suggesting a collaborative approach. Anthem proposed that CMS incentivize providers to collect and report patient race and ethnicity data (though Anthem does not go into detail on the structure of those incentives). Some insurers suggest that providers contracting with marketplace insurers could be required to complete cultural sensitivity and implicit bias trainings.

Improving Data Collection Processes

Stakeholders were asked to discuss data currently collected by marketplace insurers, potential requirements to collect data, and the challenges that these requirements would present to insurers.

The stakeholders in our sample unanimously supported efforts to improve data collection efforts. One theme touched on by almost all commenters was the need for a nationally standardized system for collecting and measuring data. Stakeholders expressed different views on best practices for collection, how to use data, and approaches to non-compliance. State DOIs and marketplaces generally favored requiring insurers offering marketplace health plans to conduct some data collection related to health equity. California’s DOI highlighted as a potential model their own guidance to insurers for collecting data on provider networks, as well as standards for cultural competency.

Some consumer advocates and insurers argued that the process for collecting demographic and social determinants of health (SDOH) data should include trusted community leaders, suggesting efforts to improve data collection by insurers will otherwise be hampered by mistrust among marginalized communities. AHIP pointed to the high rates of “unknown” and “other” responses in U.S. Census data, suggesting collection methods might need adjustments to improve response and accuracy rates. The NAIC and the Massachusetts marketplace suggested that HHS implement standards governing the language used to gather data, citing several studies evaluating the best methods for demographic data collection. Until new standards are operationalized, AHIP proposed that CMS use Social Vulnerability Index (SVI) scores as a potential short-term solution. Because this data is almost entirely self-reported and there is no national standardization, marketplace insurers were unanimous in their opposition to being penalized for failure to hit data targets.

The process of developing and implementing national standards on collecting demographic data will take time and require collaboration across stakeholders. Several stakeholders, however, noted that efforts to expand upon and improve SDOH data collection efforts do not have to start from scratch, but rather can take advantage of existing systems, such as the U.S. Census data and efforts by state and federal regulators. In Massachusetts, for example, the state’s marketplace recently collaborated with the state Medicaid agency to streamline and improve application questions gathering race and ethnicity data. However, multiple insurers including Anthem, BCBSA, Centene, Cigna, and Kaiser Permanent noted that the current lack of interoperability across systems will continue to present a challenge. Accordingly, these insurers urge CMS to consider interoperability a key focus as data standards are developed. While marketplace insurers can play a role in advancing health equity, Anthem, BCBSA, and other insurers reminded CMS that they often have little ability to influence key factors contributing to disparate health outcomes, such as a person’s housing, environment, education, and access to employment.

Promoting and Incentivizing Health Equity in the ACA Marketplaces

CMS asked stakeholders to provide feedback on other means of assessing and promoting health equity.

NPWF encouraged CMS to review their new report, which describes a framework for evaluating whether a given policy or proposal will promote equity. Massachusetts described efforts to review marketplace plans for discriminatory benefit and formulary designs that unearthed concerning practices, including prior authorization for substance use disorder medications. Along the same lines, the Transgender Law Center submitted a recent report documenting evidence of anti-transgender discrimination in marketplace coverage of care for gender dysphoria and encouraged CMS to conduct more systematic reviews of this type.

Insurer responses highlighted additional tactics for CMS to consider that could promote health equity. Anthem and BCBSA requested additional guidance from CMS on  whether a program qualifies as Quality Improvement Activity (QIA) for MLR reporting. More clarity on this issue could encourage more insurers to invest in QIA programs that advance health equity. Additionally, one insurer argued for accounting for gender identity and sexual orientation in risk adjustment calculations, such as including gender dysphoria as a condition category and PrEP as a prescription drug category (BCBSA). Kaiser Permanente supported a CMS-led effort to implement quality and equity performance incentives. Lastly, Cigna requested that CMS alleviate cost-sharing burdens for services that are ancillary to preventive care.

Looking Ahead

The stakeholders in our sample expressed broad support for CMS’ efforts to advance health equity. Although views varied on whether and to what extent to impose additional accreditation or other requirements on plans for marketplace certification, there was a consensus across stakeholders that CMS should develop national standards on health equity data collection and reporting. Several state commenters also highlighted their own innovative and promising initiatives to promote health equity, some of which could provide a model for efforts on a more national scale.

A Note on Our Methodology

This blog provides a summary of comments submitted by stakeholders in response to the request for feedback on future health equity initiatives. This is not intended to be a comprehensive review of all comments responding to this request, nor does it capture every component of the reviewed comments. To view more stakeholder comments, please visit https://www.regulations.gov/.