Stakeholder Perspectives on CMS’s 2024 Notice of Benefits and Payment Parameters: Consumer Advocates

By Kristen Ukeomah and Karen Davenport

In December, the Centers for Medicare & Medicaid Services (CMS) released its proposed Notice of Benefits and Payment Parameters (NBPP) for plan year 2024, an annual rule that governs the Affordable Care Act (ACA) health insurance Marketplaces and establishes standards for health insurers. The CHIR team has reviewed the comments submitted by select stakeholder groups in response to the proposed rule. For the first blog in our series, we looked at comments submitted by health insurers and representative associations. In this second blog, we summarize comments from consumer advocacy organizations, including:

While these organizations provided comments on a number of issues, this blog focuses on four primary topics: network adequacy, door-to-door enrollment assistance, re-enrollment decision hierarchies, and standardized plans.

Network Adequacy

For plan year 2024, CMS proposed requiring more Marketplace plans to use provider networks that comply with network adequacy and essential community provider (ECP) requirements, eliminating a previous exemption for plans without a provider network. In addition, the 2024 NBPP would modify the ECP standards by creating two new ECP categories for Mental Health Facilities and Substance Use Disorder (SUD) Treatment Centers. Moreover, HHS proposes a requirement for insurers to demonstrate compliance with the wait time standards established in 2023.

All of the consumer groups in our sample support the provider network requirement. NHeLP notes that non-network plans make it difficult for federal regulators to ensure that plan enrollees have access to care. In addition, all of the groups in our review approve of the two new ECP categories. Community Catalyst emphasizes the importance of ECPs for communities of color and other underserved communities. AARP similarly notes how the two new ECP categories will help dismantle barriers to quality care for older Americans. Families USA strongly supports these additions, further advocating for standards related to behavioral health services to separately examine adequacy for adults and children.

A couple of consumer groups also discussed the appointment wait time standards, generally supporting the policy. ACS-CAN believes that quantitative standards, like wait times, are essential in determining the adequacy of a plan’s network. Families USA urges CMS to formalize guidance around wait times in regulations, as opposed to changing these measures every year.

Door-to-Door Assistance

CMS also proposed rescinding the prohibition on Navigators, Certified Application Counselors (CACs), and non-Navigator assistance providers (“Assisters”) from going door-to-door to help consumers enroll in health insurance. CMS asserts that prohibiting door-to-door outreach inhibits the ability to assist consumers with limited capacity to travel, whether due to disabilities, being immunocompromised, or a lack of transportation.

Advocacy organizations shared a variety of opinions regarding this proposal. Community Catalyst and NHeLP support the repeal of the prohibition, citing the critical role assisters can play in Marketplace enrollment, particularly as millions of people transition off of Medicaid. NHeLP points out that door-to-door assistance would help enroll hard-to-reach individuals and families, including communities without consistent technology access, as well as consumers who do not speak English and those with disabilities.

However, other advocacy groups warn that door-to-door enrollment assistance, which may require individuals to share sensitive personal and financial information with strangers, would open the door for scams, such as identity theft. Families USA notes that although door-to-door outreach can be beneficial for reaching specific communities, many Americans cannot distinguish true Navigators and assisters from scam artists. ACS-CAN also flags that people will likely respond negatively to someone at their door appearing to “sell insurance.” These organizations opposed this policy, urging that, if CMS goes forward with the proposal, the agency should implement anti-fraud safeguards, such as extensive public health education on how to identify legitimate assisters and a requirement for assisters to provide paper documentation the consumer. Advocacy organizations in favor of lifting the prohibition also suggested establishing anti-fraud protections.

Re-Enrollment

If a consumer remains eligible for qualified health plan (QHP) coverage but does not actively choose a plan during re-enrollment, a “re-enrollment hierarchy” prioritizes keeping the consumer in the same plan or, if that plan is not available, at the same metal level. In the proposed 2024 NBPP, CMS presented new policies Marketplaces could use to automatically re-enroll certain Marketplace consumers into QHPs designed to help consumers maximize potential out-of-pocket cost savings. Under this approach, bronze plan enrollees who are income-eligible for cost-sharing reductions (CSRs) would be automatically moved to a silver plan, so they can enroll in a plan eligible for cost-sharing reduction subsidies. If an enrollee’s QHP is no longer available, CMS proposed taking the consumer’s current provider network into consideration when re-enrolling the consumer into a different QHP. In addition, CMS requested comments on whether Marketplaces should consider net premium and total out-of-pocket costs when re-enrolling consumers in future years.

Several advocacy organizations in our sample at least partially support these changes. NHeLP cites research indicating that 30 percent of households automatically renewed into coverage would be better off in a different plan. Community Catalyst applauded the proposal, as well as CMS’ effort to prioritize placing people into plans with similar provider networks, noting that doing so could mitigate consumers’ risk of incurring medical debt if they were to unintentionally receive care from out-of-network providers. Similarly, ACS-CAN underscores the importance of maintaining in-network relationships for cancer patients in active treatment and for survivors of rare cancers. NHeLP, however, suggests prioritizing affordability rather than continuity of carriers and product lines when consumers do not affirmatively choose a new plan, while Community Catalyst recommends that CMS treat net premiums and anticipated cost-sharing as separate variables for re-enrollment in future rulemaking.

Standardized and Non-Standardized Plans

In the 2023 plan year, CMS instated a requirement that insurers offering QHPs in the Federally Facilitated Marketplace (FFM), or in State-based Marketplaces use the federal platform (SBM-FP), must also offer standardized—and easily comparable—cost-sharing and benefit designs wherever they offer “non-standardized” plans. This means that for every insurance product, at every metal level, and in every geographic market an insurer offers non-standardized plans, they must also offer a standardized plan.

For 2024, CMS intends to retain the standardized plan requirement with some modest changes, such as no longer requiring insurers to offer a standardized plan at the non-expanded bronze level, and requiring insurers to place covered drugs into appropriate cost-sharing tiers. In a more significant change, however, CMS proposed limiting the number of non-standardized plan options insurers may offer. Under the proposed rule, insurers offering QHPs in the FFM and SBM-FPs would be able to offer only two non-standardized plans per product network type and metal level (except for catastrophic plans) in any service area. CMS also offered an alternative approach to this numerical limit on non-standardized plans, which would require insurers’ offerings to be “meaningfully different” from one another. Under this approach, CMS would group plans by county, insurer, metal level, product network type, and deductible integration, requiring QHPs within each group to have at least a $1,000 difference in deductibles.

All of the consumer advocacy groups in our sample applaud the proposals to simplify the consumer shopping experience by continuing the standardized plan requirement and limiting “choice overload,” which can occur when consumers face too many plan options and struggle to differentiate between products. NHeLP notes that “the usual understanding that more is better for the consumer does not hold true in the Marketplace. On the contrary, the high number of plan options often leads to confusion among shoppers, which in turn gives way to consumer errors during plan selection.” Some organizations, such as Community Catalyst, NHeLP, and ACS-CAN urge CMS to both limit the number of non-standardized plans insurers could offer and apply a meaningful difference standard to multiple QHP offerings.

A Note on Our Methodology

This blog is intended to provide a summary of comments submitted by consumer advocacy organizations. This is not intended to be a comprehensive review of all comments on every provision in the Notice of Benefit and Payment Parameters proposed rule, nor does it capture every component of the reviewed comments. To view more stakeholder comments, please visit https://www.regulations.gov/.