On April 18, 2019, the Department of Health and Human Services (HHS) released the final 2020 notice of benefit and payment parameters. This final rule outlines policies for qualified health plans (QHPs), the exchanges, and navigators. These policies will be effective for the 2020 plan year.

HHS Will Allow Plans to Exclude Value of Copay Coupons in OOP Calculation When a Generic Is Available but Declines to Make Other Drug-Related Changes

As part of an administration-wide effort to lower prescription drug spending, HHS proposed the following new changes for 2020 that were designed to reduce utilization of brand-name drugs once a generic alternative became available:

• Allow plans to make mid-year formulary changes to include a generic when it becomes available and increase cost-sharing or drop coverage of brand-name drugs at that time;
• When an individual purchases a branded product, allow plans to not count the difference in cost sharing between the brand and generic equivalent towards an individual’s out-of-pocket maximum

In public comments submitted on the proposed rule, many stakeholders were opposed to these policies. Related to mid-year formulary changes, commenters said that this policy would inappropriately expand or narrow an issuer’s ability to make mid-year formulary changes. Federal law does not prohibit this type of formulary change and commenters said that this type of change occurs more broadly than what HHS’ proposal would allow. Other commenters expressed concern that the proposal would improperly allow mid-year formulary changes and said it would hurt consumers. For the proposed policy to not count the difference in cost sharing between a brand drug and generic equivalent, commenters expressed concern over the administrative cost and burden of implementing this policy. In response to this feedback, HHS has decided not to finalize these policies. The agency says it will continue to monitor the issue of mid-year formulary changes and may provide guidance on this in the future.

However, HHS has decided to finalize a third prescription drug proposal. Beginning with 2020, HHS will allow plans to not count the value of manufacturer co-pay coupons towards an individual’s out-of-pocket (OOP) maximum if there is a generic alternative available. The agency believes that this policy will promote appropriate prescribing and purchasing choices by physicians and patients based on the true costs of drugs and price competition in the market.

Annual Cost Sharing Limits Will Increase in 2020

HHS is finalizing a 2020 maximum annual cost-sharing limit of $8,150 for individual coverage and $16,300 for family coverage. These limits represent an increase of just over 3 percent above the 2019 parameters which were $7,900 for individual and $15,800 for family coverage. These are slightly lower than the cost-sharing limits in the proposed rule.

“Enhanced” Enrollment Pathway for Non-Exchange Websites Finalized

In an effort to broaden options for enrollment in QHPs, HHS finalized their proposal to offer an “enhanced” direct enrollment pathway for web brokers offering access to QHPs separate from HealthCare.gov. The enhanced pathway will allow web brokers to access Exchange eligibility application and enrollment services without redirecting traffic to HealthCare.gov. This finalized provisions also provides options to receive more comprehensive services and access ongoing support without the need to redirect; classic direct enrollment will still be available.

HHS Finalizes Proposal for Individuals and Families to Claim 2018 Hardship Exemption Via Taxes

In an effort to make it easier for individuals and families to claim a hardship exemption for 2018 (the last year of the individual mandate), HHS finalized their proposal to allow those exemptions to be filed with tax returns. Currently, individuals and families must seek a separate exemption from the Exchange. HHS is finalizing this proposal in an attempt to reduce burden on consumers.

Special Enrollment Period for Households that are Newly-Eligible for Premium Subsidies Mid-Year Finalized

A new special enrollment period, during which time an individual or family would be able to enroll in a QHP, will be added in 2020 that allows households that experience a drop in household income significant enough that would make the household eligible for premium tax credits, to enroll in a QHP; enrollment must happen within 60 days of the financial change.

Requirements for Navigators Relaxed

HHS is finalizing their proposal to relax the requirements that Navigators operating in states with federally-facilitated exchanges offer assistance, on a number of topics not specifically mentioned in the statute. These services will become optional for Navigator grants awarded in 2019 or later. The agency hopes to allow for flexibility in the Navigator program with this change.

HHS Continues to Seek Comments on Automatic Re-Enrollment

HHS sought comments in their proposed rule on the current practice of automatic reenrollment for some beneficiaries. HHS is not finalizing automatic reenrollments at this time; however, the agency notes that automatic re-enrollment could decrease administrative expenses and is consistent with industry practices. HHS states that they will continue to consider feedback provided from stakeholder for potential automatic re-enrollment in future rules.

HHS Requests Comments on Interoperability Rule Released in March

In the proposed rule, HHS requested public input on interoperability of patient-mediated health care data. On March 4, 2019, CMS published their Interoperability and Patient Access Proposed Rule which seeks further input on the development of methods that enables patients to easily access their health data. HHS requests those that are interested to comment on those provisions. The agency recently extended the comment period to June 3, 2019.