2024 Marketplace Final Rule Changes Agents Should Know

Recently, the Centers for Medicare & Medicaid Services (CMS) released their HHS Notice of Benefit and Payment Parameters for 2024 final rule. We’ve noted the changes marketplace agents should be aware of for the 2024 Open Enrollment Period and beyond.

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The Department of Health & Human Services (HHS) Notice of Benefit and Payment Parameters for 2024 final rule finalizes standards for issuers, marketplaces, agents, brokers, web-brokers, and assisters (navigators, non-navigator assistance personnel, and Certified Application Counselors). Included are changes that will affect your Affordable Care Act (ACA) clients’ plan choices, coverage, coverage effective dates, and SEP availability. There are also two important changes related to items agents selling marketplace plans will need to document moving forward.

You can read the full 2024 marketplace final rule here. Most of these changes go into effect for the 2024 plan year (PY2024), but some have other specified implementation dates.

Here’s a summary of what you need to know.

Changes That Will Affect Marketplace Agents

Required Prior to Providing Consumers Assistance

CMS has finalized an HHS requirement that agents must be able to provide proof they’ve received consent from a consumer, or their authorized representative, to help them with their ACA coverage decisions. Agents must retain this documentation for a minimum of 10 years and produce it upon request.

While there’s no official form to document this consent, Ritter’s Compliance and Under-65 teams have created a form that satisfies this requirement. Read more about this new requirement in our blog post on the subject.

Agent Documentation of Consumer Review of Application

Consumer Must Confirm All Info Is Accurate Before Application Submission

Agents must also document that the consumer, or authorized representative, has reviewed and confirmed all eligibility application information prior to applying. Like the consent documentation, agents must retain this documentation for a minimum of 10 years and produce it upon request.

Currently, there’s no official form to document this consent.

Longer HHS Review Period for Agent Rebuttals

For Suspensions or Terminations of Marketplace Agreements

CMS has granted HHS 15 more days, 45 calendar days total, to review agent-submitted evidence to rebut allegations that resulted in the suspension of their marketplace agreement(s) and inform the agent of their decision. HHS will have 30 more days, 60 calendar days total, to review termination reconsiderations and inform agents of their decisions.

Includes Upon First Contact

Assisters (navigators, non-navigator assistance personnel, and Certified Application Counselors) can conduct door-to-door enrollment assistance. (Agents can too, unless there’s specific guidance from their state’s Department of Insurance stating otherwise.)

This will make it important for you to ensure your clients understand the value of working with licensed agents like you for assistance.

Changes That Will Affect Your Marketplace Clients

Bronze to Silver Crosswalk Policy

When Automatically Re-Enrolling Enrollees Eligible for CSRs

Enrollees who are eligible for cost-sharing reductions (CSRs) and enrolled in a bronze-level qualified health plan (QHP) can be automatically re-enrolled in a silver-level QHP in the same product and provider network as long as the premium, after application of the Advanced Premium Tax Credit, is lower or equivalent to the premium of the bronze-level QHP the enrollee would have otherwise been re-enrolled in.

The Bronze to Silver Crosswalk Policy for automatic re-enrollment will take effect on the federal platform for PY2024.

This policy takes effect in marketplaces on the federal platform for PY2024.

Network Similarity Re-Enrollment Criteria

For Enrollees with QHPs/Products No Longer Offered

If an enrollee has a QHP or product that will not be available the next plan year and is being auto-enrolled in a similar plan, that plan must have a similar network, beginning in PY2024. This rule applies to both federal and state-based marketplaces (SBMs).

New SEP for Loss of Medicaid/CHIP

Will Generally Last 90 Days

Starting January 1, 2024, marketplaces can implement a new special enrollment period (SEP) for consumers losing Medicaid or Children’s Health Insurance Program (CHIP) coverage that’s considered minimum essential coverage. The SEP will last 90 days after the loss of coverage, aligning with the 90-day Medicaid or CHIP reconsideration period.

SBMs will be able to provide consumers qualifying for the SEP with more time to select a QHP if the state’s Medicaid or CHIP reconsideration period is longer. They’ll also be able to implement the rule sooner, upon the Final Rule taking effect, if they so choose.

Currently, there’s a temporary SEP with the Medicaid unwinding in effect for the federally facilitated marketplace through July 2024.

Earlier Coverage Dates If Losing Minimum Essential Coverage

Optional for Marketplaces to Offer

For consumers attesting to a future loss of minimum essential coverage (MEC), marketplaces will be able to offer earlier coverage dates, potentially helping consumers avoid gaps in coverage.

If a consumer attests on April 18 that they will lose MEC on June 18 and applies for a plan on May 28, their coverage could be effective June 1.

Plan Display Error SEP Changes

New Error Added & Proof Will Not Fall Solely On Consumers

If a consumer is requesting an SEP due to their plan choice being influenced by erroneous plan materials on benefits, service area, premium, or cost-sharing, other interested parties may submit proof on the consumer’s behalf. CMS has added cost-sharing to the types of plan display errors that may allow for such an SEP.

CMS has added cost-sharing related errors to the types of plan display errors that may allow for a SEP.

Specified Method of Age Calculation for SADPs

Issuers Must Use Enrollee’s Age on Effective Date

Beginning with PY2024, marketplace-certified stand-alone dental plans (SADPs), sold on- or off-marketplace, must use an enrollee’s age on effective date to calculate their age for rating and eligibility purposes. This revision aims to remove the more difficult age calculation methods and reduce consumer confusion.

Marketplace QHPs and SHOP Plans Must Use an Adequate Network

Must Comply with Essential Community Provider (ECP) Regulations

All individual market QHPs and all small business health option program (SHOP) plans* must meet network adequacy and essential community provider standards. CMS has removed the exception that these standards need not apply to plans without a provider network.

This revision aims to ensure consumer access to an adequate selection of providers.

*Includes QHP and SHOP SADPs, except for those that sell plans where it’s “prohibitively difficult” for the issuer to establish a network of dental providers.

Essential Community Provider Category Changes

Includes Two New Categories & Retained Thresholds

To increase access to care for low-income and medically underserved consumers, CMS has established two new major Essential Community Provider categories for plan year 2024 and beyond: Mental Health Facilities and Substance Use Disorder Treatment Centers. CMS has also added rural emergency hospitals to the Other category.

CMS has established two new major Essential Community Provider categories for plan year 2024 and beyond: Mental Health Facilities and Substance Use Disorder Treatment Centers.

Going forward, CMS is retaining the 35 percent threshold for Federally Qualified Health Centers and Family Planning providers.

Removal of Standardized Plan Option

Applies to Non-Expanded Bronze Metal Level

Starting for PY2024, QHPs on the federally facilitated marketplace and SBMs will not need to offer standardized plans designed by CMS at the non-expanded bronze level.

It’s important to note not all SBMs have adopted a version of standardized plans (e.g., PA has not). Non-standardized plans could include dental, vision and other benefits and could have tiered networks.

A limitation on the number of standardized plans by market could lead to plan disruptions for members.

Non-Standardized Plan Option Limits

Four per QHP Issuer for PY2024 & Two for PY2025 & Beyond

QHPs on the federal platform, including SBMs on the federal platform will be limited to four non-standardized plan options per product network type, metal level (excluding catastrophic plans), and dental and/or vision benefit coverage for PY2024. For PY2025 and beyond, the limit will drop to two. CMS includes exceptions/additional clarifications in the full Final Rule.

With these changes, CMS aims to reduce the weighted average number of plans offered to each consumer from about 114 (PY2023) to 91 (PY2024), and subsequently, decrease plan choice overload, suboptimal plan selection, and unexpected financial harm to consumers.

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The HHS 2024 Notice of Benefit and Payment Parameters Final Rule generally aims to make coverage more accessible, strengthen plans, and simplify plan choice for 2024. While there are only a few 2024 Marketplace Final Rule changes that directly impact agents, it’s important to ensure you understand them, so you can stay compliant selling ACA insurance going forward. If you have any questions about these changes, please email our Compliance Officer at [email protected].

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