The Patient Protection and Affordable Care Act (ACA) and applicable regulations provide that health plans must meet a number of standards in order to be certified as Qualified Health Plans (QHPs).
In response to the ACA, the Center for Medicare and Medicaid Services (CMS) issued April 18, 2019, a letter to insurance companies and states identifying provisions of health insurance that must be met beginning in 2020. Initial activity begins May 22, followed by the various changes throughout the reminder of 2019. Open enrollment begins November 1, 2019.
The approach for reviewing issuers’ prescription drug benefit offerings remains unchanged from that used in 2018. In response to the ongoing nationwide public health emergency, opioid use disorder was added as a condition to the clinical review in 2019 and will continue to be used during plan year 2020 reviews.
Additionally, CMS does not conduct active certification reviews for formulary outliers for states that perform plan management functions, and instead defers to those state processes. CMS will continue to review for formulary outliers in states that do not perform plan management functions.
Overall, the rule minimizes the number of significant regulatory changes to provide states and issuers with a more representative, stable, and predictable regulatory framework that facilitates a more efficient and competitive market.
The changes finalized in the rule are targeted to further the goals of lowering premiums, increasing market stability, reducing regulatory burdens, enhancing the consumer experience, and reducing federal expenditures.
In furtherance of the Administration’s priority to reduce prescription drug costs and to align with the President’s American Patients First blueprint, CMS finalized a change to the prescription drug benefit, to the extent permitted by applicable state law, which is designed to encourage use of lower-cost generic drugs.
Beginning in 2020, CMS will allow individual market, small group, large group and self-insured group health plans to except from the maximum out-of-pocket limit cost sharing amounts paid using drug manufacturer coupons for specific prescription brand drugs that have an available and medically appropriate generic equivalent.
