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The Department of Health and Human Services (“HHS”) released its final rule on benefit and payment parameters under the Affordable Care Act (“ACA”) for the 2020 plan year. In general, HHS largely finalized the rule as proposed, though there are a few changes it opted not to implement. Like the proposal, the final rule does not directly address many of The Council’s core interests related to the ACA. It does, however, touch some of the more tangential policy issues we have been following:

  • Expands opportunities for direct enrollment via third parties websites (i.e., “direct enrollment entities,” “web brokers,” “application assisters,” etc.) and streamlines the regulatory requirements applicable to such entities, though—unlike the proposed rule—it retains the provision of existing law that prohibits the use of web-broker websites by assisters like navigators;
  • Allows insurers—to the extent permitted by state law—to count any form of direct support offered by drug manufacturers (e.g., coupons) towards the deductible or annual maximum limit on out-of-pocket costs when a “medically appropriate generic equivalent” to a brand-name drug is available;
  • Does not finalize all of the proposed changes regarding prescription drug benefits (e.g., does not permit insurers to update their prescription drug formularies mid-year to optimize the use of new generic drugs as they become available, alter the treatment of certain brand-name drugs as essential health benefits (“EHB”), etc.);
  • Addresses upcoming deadlines for states seeking to implement EHB benchmark plans;
  • Reduces navigators’ post-enrollment assistance duties (e.g., makes it optional—rather than mandatory—for navigators to assist consumers with the process of filing eligibility appeals, components of the premium tax credit reconciliation process, etc.) and eliminates the requirement that exchanges train navigators in these post-enrollment activities; and
  • Allows federally-facilitated Small Business Health Options Programs to operate a toll-free telephone hotline instead of a call center.

The final rule also covers several other ACA, and exchange related topics, which may be of more general interest to Council members, including:

  • Does not prohibit “silver loading,” but reiterates that the Administration supports a legislative solution that would appropriate cost-sharing reduction payments;
  • Recalibrates the risk adjustment models for the 2020 plan year; and
  • Revises the premium adjustment percentage to 1.29%, adjusting the maximum annual out-of-pocket limit on cost sharing for self-only coverage to $8,150 (and $16,300 for other than self-only coverage), and sets the required contribution percentage at 8.24% for the 2020 plan year.

Though HHS proposed no formal policy changes, it solicited feedback on a variety of ways to increase data transparency throughout the health care ecosystem: efforts to evaluate regulatory pathways that would provide consumers with greater transparency as to their own health care data; qualified health plan offerings on the federally-facilitated exchanges; and the cost of health care services. HHS notes in the final rule that, while it is not making changes to implement specific transparency requirements, it will consider comments received on these issues in future proposals. Here is a link to a Steptoe memo regarding the proposed rules to improve individuals’ access to their health data and how to facilitate its interoperability.

The final rule can be found here.