Key Changes for PY2024

As delineated in the HHS Notice of Benefit and Payment Parameters for 2024, CMS requires that plans across all Exchange types use a network of providers that complies with Sections 45 CFR 156.230 and 45 CFR 156.235. CMS allows for a limited exception to the provider network requirement for SADPs that sell plans in areas where it is prohibitively difficult for the issuer to establish a network of dental providers. Under this exception, an area is considered “prohibitively difficult” for an SADP issuer to establish a network of dental providers based on attestations from State Department of Insurance in states with at least 80% of their counties classified as Counties with Extreme Access Considerations, that at least one of the following factors exists in the area of concern: a significant shortage of dental providers, a significant number of dental providers unwilling to contract with Marketplace issuers, or significant geographic limitations impacting consumer access to dental providers. The exception that these sections do not apply to plans without a provider network is no longer in place. Under this rule, a plan cannot be certified if it does not use a network of providers that complies with network adequacy standards. Refer to the ECP and Network Adequacy webpage for more information. 

CMS requires that plans across all Exchange-types must use a network of providers that complies with sections 45 CFR 156.230 and 45 CFR 156.235 of the HHS Notice of Benefit and Payment Parameters for 2024, with the limited exception for certain SADPs described above. The exception that these sections do not apply to plans without a provider network is no longer in place. Under this rule, a plan cannot be certified if it does not use a network of providers that complies with ECP standards. Additionally, CMS requires the application of the 35 percent threshold to two of the major ECP categories: Federally Qualified Health Centers (FQHCs) and Family Planning Providers. Medical QHP issuers need to contract with at least 35 percent of available providers in the plan’s service area for both of these categories; SADP issuers need to contract with at least 35 percent of FQHCs offering dental services in the plan’s service area. These contracts—for both QHPs and SADPs—will also count toward the overall 35 percent threshold, which remains in place. Finally, there are new additions to the ECP provider types and categories. Rural Emergency Hospitals are now a provider type in the Other ECP Providers major ECP category, and there are two new major ECP categories: Substance Use Disorder Treatment Centers and Mental Health Facilities. Refer to the ECP and Network Adequacy webpage for more information. 

Per the HHS Notice of Benefit and Payment Parameters for 2024, SADP issuers are required to use an enrollee’s age at the time of policy issuance or renewal (referred to as age on effective date) as the sole method to calculate an enrollee’s age for rating and eligibility purposes. This requirement is a condition of QHP certification, beginning with Exchange certification for PY2024. This requirement also extends to all Exchange-certified SADPs, whether they are sold on- or off-Exchange. Refer to the Business Rules webpage for more information.