CMS Lowers Maximum Out-of-Pocket Costs for 2022 Federal Health Insurance Marketplace Plans

CMS today adopted new provisions to lower maximum out-of-pocket costs to consumers by $400. The second 2022 Notice of Benefit and Payment Parameters final rule (also known as the “2022 payment notice”) includes several provisions to help consumers more easily distinguish between plan options and increase opportunities to qualify for future special enrollment periods (SEPs), when consumers are eligible to enroll in marketplace plans outside annual open enrollment. These SEP policies will offer greater flexibility for those who need coverage—particularly those communities hardest hit by COVID-19. Already, an additional 800,000 Americans have enrolled in the ACA under the SEP enacted by the Biden Administration.

The annual payment notice makes regulatory changes in the individual and small-group health insurance markets, and outlines parameters and requirements issuers need to design plans and set rates for the upcoming plan year. The notice also includes regulatory standards to help states, the marketplaces, and insurance issuers in the individual and small-group markets better serve consumer needs.

The new SEP policies, for example, will expand the opportunities consumers have to sign-up for health coverage outside the annual open enrollment period. This includes offering consumers an SEP when they have not received timely notice (and were reasonably unaware) of events that would allow them to qualify, and when they no longer receive employer contributions or government subsidies (such as those provided under the American Rescue Plan Act of 2021) for continued employer health coverage under the Consolidated Omnibus Budget Reconciliation Act (or “COBRA”).

For consumers, the second phase of the 2022 payment notice expands options for accessing coverage. It also breaks down barriers—like high costs—that too often have put health care out of reach, particularly in underserved communities. The rule finalizes a maximum annual limitation on cost-sharing that is $400 below what CMS proposed in November 2020.

Additionally, revised measures establishing parameters for determining insurance affordability and cost sharing will allow consumers to purchase lower-priced plans. These allow those age 30 and over to apply for catastrophic coverage (coverage that generally offers lower-priced plans to protect someone from high medical costs). The calculations will slow the growth rate for cost-sharing, which might otherwise place an undue burden on sicker and lower-income enrollees, and when adopted by the Internal Revenue Service, will also expand eligibility for tax credits to reduce the cost of health insurance premiums for lower-income enrollees.

A number of other provisions will make it easier for consumers to comparison shop for plans, as well as improve support for the Federal Health Insurance Marketplaces, health insurance issuers, and other stakeholders who facilitate access to coverage.

For further information on provisions in the second 2022 payment notice final rule, see the CMS fact sheet by clicking here.

The full rule will be published on the Federal Register on 5/5/21. Until then it is available at this link as an “unpublished” PDF.

The ongoing pandemic has forced many people to change their insurance. Be sure that your staff asks patients about changes to their insurance before it becomes an issue!