Key Consumer Protection Measures
The Biden administration’s final rule, set to take effect Wednesday, introduces robust consumer safeguards in the individual healthcare market. This groundbreaking legislation prevents unauthorized coverage changes and implements strict penalties for brokers and agents who violate these protective measures.
Risk Adjustment and Premium Modifications
The comprehensive reform introduces significant changes to the risk adjustment program, incorporating new user fee rates and calculations for the Basic Health Program. Cost-sharing reduction loading will be permitted when actuarially justified, particularly benefiting those without enhanced premium tax credits.
Health Equity Advancement Initiatives
To promote marketplace efficiency and health equity, the Centers for Medicare & Medicaid Services (CMS) has revolutionized non-standardized plan offerings. This strategic modification specifically targets the treatment of chronic and high-cost conditions, addressing health disparities across communities.
Enhanced Premium Payment Framework
The final rule establishes a consumer-friendly premium payment structure, featuring:
- A fixed-dollar threshold capped at $10
- A gross premium threshold set at 98%
- Flexible payment options to maintain coverage continuity
Risk Adjustment Model Updates
The reformed risk adjustment model incorporates data from 2020-2022 for the 2026 benefit year, with specific modifications for:
- Hepatitis C drug considerations
- Pre-exposure prophylaxis factors
- Medical loss ratio calculations
Marketplace Fee Structure
The rule finalizes marketplace fee rates with precise allocations:
- 2.5% of monthly premiums for federally facilitated marketplaces
- 2% for state-based marketplaces utilizing federal platforms
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