Standardized Plan Options FAQs

Standardized Plan Optionsⁱ

Q1: At which metal levels are issuers required to offer Standardized Plan Options?

• Under the Notice of Benefit and Payment Parameters for 2024 final rule at 45 CFR 156.201, issuers offering QHPs through FFEs and SBE-FPs are required to offer Standardized Plan Options at every product network type (as described in the definition of “product” at § 144.103), at every metal level except catastrophic and non-expanded bronze, and throughout every service area that they offer non-standardized plan options. If an issuer is offering a non-expanded bronze non-standardized plan option, they should offer an expanded bronze standardized plan option at that product network type and service area in order to satisfy the obligation to offer a Standardized Plan Option plan at the bronze metal level.

Q2: Are tiered provider networks permitted for Standardized Plan Options?

• No, Standardized Plan Options are not permitted to have multiple in-network provider tiers. 

Q3: Are issuers offering Standardized Plan Options required to offer Indian CSR plan variations as provided for at § 156.420(b) in connection with the Standardized Plan Options plans they offer?

• Yes. Consistent with our approach in the Notice of Benefit and Payment Parameters 2023 final rule, in the Notice of Benefit and Payment Parameters (NBPP) 2024 final rule, we did not finalize standardized plan options for the Indian CSR plan variations as provided for at 45 C.F.R. 156.420(b), given that the cost-sharing parameters for these plan variations are already largely specified.
  
  More specifically, the zero cost-sharing plan eliminates all cost sharing for covered essential health benefits (EHB), and the limited cost-sharing plan uses the same cost-sharing parameters as the non-CSR plan variation, but with no cost sharing on any item or service that is an EHB furnished directly by the Indian Health Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization (each as defined in 25 U.S.C. 1603), or through referral under contract health services. Therefore, we did not specify cost-sharing parameters for these plan variations, because § 156.420 specifies how such plan variations must be designed based on the applicable non-CSR plan variation standardized plan options plan.
  
  As such, consistent with our approach in the Notice of Benefit and Payment Parameters for 2023 final rule, for PY 2024, issuers continue to be required to offer these plan variations for all standardized plan options offered.
  
  Finally, in the NBPP 2024 final rule, we removed the regulation text language at § 156.201 stating that standardized plan options for these plan variations are not required to be offered. We further clarified that while issuers must, under § 156.420(b), continue to offer such plan variations based on standardized plan options, those plan variations will themselves not be standardized plan options based on designs specified in this rulemaking (pp. 25847-25848).

Q4: What cost-sharing parameters should issuers apply for covered benefits that are not included in Standardized Plan Options in the Notice of Benefit and Payment Parameters for 2024 final rule?

• Issuers have discretion to determine the cost sharing for covered benefits not included in the standardized plan options in the Notice of Benefit and Payment Parameters for 2024 final rule, provided the plan design continues to meet actuarial value requirements, and subject to other applicable Federal and State law.

Q5: Does the “Mental Health and Substance Use Disorder Outpatient Office Visit” benefit category copay only apply to office visits? Or does it also apply to non-office outpatient services and facilities?

• Generally, under the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) and implementing regulations,^[1] financial requirements (such as deductible, coinsurance, or copayment) and quantitative treatment limitations (such as day or visit limits) that apply to MH/SUD benefits must be no more restrictive than the “predominant” financial requirements or quantitative treatment limitations that apply to “substantially all” medical/surgical benefits in a classification.^[2]
  
  A type of financial requirement or quantitative treatment limitation is considered to apply to “substantially all” medical/surgical benefits in a classification if it applies to at least two-thirds of all medical/surgical benefits in that classification. The level that is considered “predominant” is the level that applies to more than one-half of medical/surgical benefits in a classification subject to the financial requirement or quantitative treatment limitation. Further, each type of financial requirement is treated separately and is subject individually to the “substantially all/predominant” test.
  
  For example, a copayment may apply to MH/SUD benefits only if copayments apply to at least two-thirds of all medical/surgical benefits in a classification, and the level of copayment for MH/SUD benefits must be no greater than the level that applies to more than one-half of the medical/surgical benefits with a copayment in the classification. The determination of the portion of medical/surgical benefits subject to the financial requirement or treatment limitation is based on the dollar amount of all plan payments for medical/surgical benefits in the classification expected to be paid under the plan for the plan year.
  
  With this context, CMS clarifies that the cost-sharing value assigned to in-network, outpatient MH/SUD services in each of the standardized plan options applies to in-network, outpatient MH/SUD office visits only. This cost-sharing value does not apply to other in-network, outpatient MH/SUD services. CMS also clarifies that for in-network, outpatient MH/SUD services other than MH/SUD office visits, the Standardized Plan Option’s coinsurance rate and deductible applies. This is consistent with CMS’ intent in designing the Standardized Plan Options to treat outpatient MH/SUD office visits similarly to the lowest cost medical/surgical office visits in terms of total out-of-pocket cost per visit.
  
  Given that neither the Plans & Benefits Template nor the corresponding Standardized Plan Option Add-In file contain two distinct benefit categories for MH/SUD outpatient v. MH/SUD outpatient office visit, issuers should explain this specification and details regarding cost sharing for MH/SUD outpatient services other than office visits in the appropriate explanation field within the Plans & Benefits Template.

Q6: Can Standardized Plan Options have a formulary with more than four tiers of prescriptions drugs in the Prescription Drug Template while effectively having four tiers of prescription drug cost sharing in the Plans and Benefits Template?

• Each standardized plan option must have the required cost sharing values, including for the generic, preferred brand, non-preferred brand, and specialty formulary tiers. Standardized plan options are limited to these four formulary tiers, with the exception of the zero cost share preventive drugs and/or the medical service drugs tiers. Refer to Tables 9 and 10 in § 156.201 of the preamble to the Notice of Benefit and Payment Parameters for 2024 final rule (2024 Payment Notice) (pp. 25850-25851) for specific plan designs.
  
  If the submitted plan's cost sharing values do not conform with the required cost sharing values in the Plans and Benefits Template, the corresponding Standard Plan Option Add-In file, and the Prescription Drug Template, or if the plan exceeds the maximum number of permitted formulary tiers, the plan will receive a deficiency and will fail to be considered a standardized plan option.
  
  Furthermore, as stated in the 2024 Payment Notice, "within the Prescription Drug Template, for standardized plan options, issuers should enter zero cost preventive drugs for tier one, generic drugs for tier two, preferred brand drugs for tier three, non-preferred drugs for tier four, specialty drugs for tier five, and medical services drugs for tier six, if applicable" (p. 25849).

Standardized Plan Options Add-in File

Q1: Will the Standardized Plan Option Add-in file automatically load in the Plans & Benefits Template?

• Unlike the Plans & Benefits Template Add-in file, an issuer must open the Standardized Plan Option Add-in file, or it will not load into the Plans & Benefits Template automatically. To load the Standardized Plan Option Add-in file, navigate to the Add-in file on the local machine and open the file. After opening the Standardized Plan Option Add-in file, it will appear at the top ribbon of the Plans & Benefits Template.
  
  If you still experience loading issues for the Standardized Plan Option Add-in file after taking the above steps, you may need to manually load the Add-in file into Excel:

1. In the Plan & Benefits Template Excel file, go to File > Options > Add-Ins > Manage: Excel Add-Ins > Go > Browse
2. Locate the Standardized Plan Option Add-in file on your local computer.
3. Select the Standardized Plan Option Add-in file and press OK.
   

The Standardized Plan Option Add-in file should now load into the Plans & Benefits Template and appear on the ribbon of the Excel file.