CMS extends special enrollment period qualifications in latest ACA rule

Affordable Care Act
The Centers for Medicare & Medicaid Services released the second part of the Notice of Benefit Payment Parameters, which outlines regulations for the ACA exchange coverage year. (Getty/zimmytws)

The Biden administration finalized a rule that makes it easier for consumers to qualify for a special enrollment period for Affordable Care Act exchange coverage, in addition to several other major changes.

The Centers for Medicare & Medicaid Services finalized on Friday the second part of the Notice of Benefit and Payment Parameters that outlines regulations on the ACA exchanges for the 2022 coverage year.  A key part of the rule was more flexibility for consumers to sign up for a special enrollment (SEP) period to get coverage outside of open enrollment.

“These [special enrollment period] policies will offer greater flexibility for those who need coverage—particularly those communities hit hardest by COVID-19,” CMS said in a release on Friday.

ACA exchange customers can qualify for an SEP if they meet certain requirements like they lost their job or got a divorce. The rule would now allow an individual to sign up for an SEP if they weren’t aware of such a triggering event or didn’t get a timely notice.

CMS also finalized a policy that codifies a recent law that says individuals with COBRA coverage could qualify for an SEP.

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More flexibility for consumers to sign up for an SEP is a departure from the Trump administration, which tightened the qualifications for the special enrollment periods. The Trump administration also shortened the open enrollment period to six weeks.

The agency is also lowering the consumers’ maximum out-of-pocket costs by $400 for the 2022 coverage year.

“The final 2022 reduced annual limitation on cost-sharing for eligible enrollees with incomes between 100% and 200% of the federal poverty level is $2,900 for self-only coverage and $5,800 for other-than-self-only coverage,” the rule said.

The limit for enrollees with an income 200 to 250% above the poverty level is $6,950 for self-coverage and $13,900 for families.

CMS also decided not to finalize several provisions in the proposed version of the rule, for example, a proposal to change web broker display requirements. CMS had proposed an exception to existing requirements that call for non-exchange websites to display certain information on qualified health plans.

“We agreed with commenters that the display of more [qualified health plan] comparative information on the web broker non-exchange websites is in the best interest of consumers to aid them in comparing [QHP] options without having to potentially navigate multiple websites,” CMS said in a fact sheet on the final rule.

The agency is also finalizing a policy that updates website display requirements for direct enrollment entities, which are carriers and web brokers that can directly enroll customers in ACA exchange plans.

Direct enrollment entities must display and market three categories of plans: QHPs, off-exchange plans and “all other products, such as excepted benefits not subject to ACA market-wide rules.”

Another major change focuses on pharmacy benefit management transparency. The rule includes a new requirement for the collection of prescription drug data directly from PBMs.

“The data will be used to enhance our understanding of the true cost of prescription drugs provided in exchange plans and shed light on the role that PBMs play in their cost,” CMS said.

This is the second part of the Notice of Benefit Payment Parameters. The first part was finalized by the Trump administration back in January. That final rule set user fees for the 2022 coverage year and encourages states to team up with private firms to create new exchanges.