By the 2020 Mom Policy Team

Last month the Biden Administration released final regulations that make critical changes to Affordable Care Act (ACA) plans for the 2023 plan year. Annually, the Administration releases proposed changes to ACA plans for the upcoming plan year with the ability for outside stakeholders to submit comments in response to the proposed changes. After reviewing the stakeholder comments, the Administration adjusts its proposal accordingly and finalizes the regulations.

The 2023 plan final rule seeks to expand access to care through the addition of guardrails to ensure insurance plan designs are comprehensive and clinically based for consumers. Highlights from the final rule are detailed below.

Ensuring Health Plans are Comprehensive and Accessible

The Administration seeks to strengthen insurance plans through the elimination of discriminatory benefit designs. Starting in 2023, ACA insurance plans must be clinically based and do not discriminate based on age, expected length of life, present, or predicted disability, degree of medical dependency, quality of life, or other health conditions. Additionally, the final rule tackles the longstanding problem of insurance plans not having a large enough network of health care providers. Narrow networks can curtail access for consumers seeking specialty services, including mental health specialists, and result in higher out-of-pocket costs or eliminate access to critical services altogether.

The final rule seeks to address these issues by adopting time and distance standards and appointment wait times to an expanded list of health care providers and facilities. The addition of health care provider specialties and facilities include emergency medicine, outpatient clinical behavioral health including inpatient and residential behavioral health facility services, and urgent care among others. Time, distance, and wait time standards will be determined at the county level based on population size. Further details on these standards will be released by the Administration at a later date.

Streamlining ACA Enrollment

The final rule will mandate plan issuers to offer a standardized plan option for each metal tier on the ACA marketplace to minimize confusion for the consumer when shopping for the best plan for themselves and their families. Further, for consumers utilizing a web broker when shopping for health care, deferential display of ACA-compliant plans must be enforced.

Last, to ensure that consumers are not unfairly penalized for past-due premiums, the final rule reverses the policy that allows plan issuers to refuse enrollment of a consumer if they have outstanding premium debt from the previous year. This policy further dissuades individuals and families from enrolling in coverage and adds an unnecessary barrier to care that will no longer continue.

What’s Next?

Although these changes to 2023 ACA plans provide strong protections for consumers and their families, there remains one large unaddressed policy. Last year, Congress passed the American Rescue Plan Act of 2021 which included expanded federal subsidies to Americans with ACA plans. This policy allowed individuals with incomes approximately above $52,000 to be eligible for subsidies for the first time resulting in 28% of enrollees paying $10 dollars or fewer per month for health coverage. However, without Congressional action, these subsidies are slated to end this year. Of the 19.6 million people estimated to be insured in the ACA marketplace, government projections estimate 3 million people would become uninsured if the enhanced subsidies expire. The states with the largest projected numbers of people losing coverage or decreased subsidies include California, Florida, Georgia, North Carolina, Pennsylvania, and Texas. More than 7.7 million people are projected to be affected in these six states alone.

Democratic lawmakers in Congress are pushing for an extension of the enhanced subsidies through the budget reconciliation process, which would allow Senate Democrats to pass legislation without Republican support. However, reconciliation has currently been mired in more controversial policy proposals and a path forward remains unclear. If a deal cannot be reached, people with ACA coverage will be notified of their premium increases in October, just ahead of the midterm elections.