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 2023 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, and throughout every service area that they offer non-standardized plan options. 

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 required to offer both standardized bronze plans and standardized expanded bronze plans in order to satisfy the Standardized Plan Options plan availability requirement?  

  • The regulation requires issuers offering QHPs through FFEs and SBE-FPs to offer Standardized Plan Options at every metal level that they offer non-standardized options. Expanded bronze plans are plans at the bronze metal level. Therefore, an issuer can offer a standardized bronze plan or a standardized expanded bronze plan in order to satisfy an obligation to offer a Standardized Plan Option plan at the bronze metal level.

    This also means that if an issuer offers both a non-standardized bronze QHP and a non-standardized expanded bronze QHP within the same service area and product network type, offering either a standardized bronze QHP or a standardized expanded bronze QHP within that service area and product network type would satisfy the Standardized Plan Options plan availability requirement.

    Though issuers are not required to offer both a standardized bronze QHP and a standardized expanded bronze QHP in this scenario, they may choose to do so. Additionally, if issuers offer only a non-standardized bronze QHP within a particular service area and product network type, offering only a standardized expanded bronze QHP (or vice versa) would satisfy the Standardized Plan Options plan availability requirement. 

Q4: 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. 45 CFR § 156.201 states that issuers are not required to provide Standardized Plan Options plans for the zero and limited cost-sharing plan variations, as provided for at § 156.420(b). We clarify that this reflects that we did not design specific Standardized Plan Options plans for these plan variations because, as noted in the preamble to the Notice of Benefit and Payment Parameters for 2023 final rule, the cost sharing parameters for the Indian CSR plan variations as provided for at § 156.420(b) are already largely specified.

    More specifically, the zero cost-sharing plan eliminates all cost sharing for covered 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 or require that they be offered as Standardized Plan Options plans, because § 156.420 specifies how such plan variations must be designed based on the applicable non-CSR plan variation Standardized Plan Options plan.

Q5: 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 2023 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 2023 final rule, provided the plan design continues to meet actuarial value requirements, and subject to other applicable Federal and State law.

Q6: 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, we clarify 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. We also clarify 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 and 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 and Benefits Template.

Q7: Are there requirements for visit limits for any of the benefit categories in Standardized Plan Options?

  • In the Notice of Benefit and Payment Parameters for 2023 final rule, we noted that “there are no visit limits for any of the benefit categories, including specialist visits, for any metal level in either of the two sets of Standardized Plan Options finalized in this rule.”3 We clarify this statement to mean that we did not standardize visit limits for any benefit categories within these Standardized Plan Options, meaning issuers retain discretion to set visit limits for particular benefits, so long as these limits comply with applicable Federal and State law.

    For example, in order to comply with EHB requirements, non-grandfathered health plans in the individual and small-group market must design their plans to provide benefits that are substantially equal to the EHB-benchmark plan including covered benefits, limitations on coverage including of benefit amount, duration, and scope, and prescription drug benefits. Additionally, to ensure compliance with MHPAEA and its implementing regulations, quantitative treatment limitations (such as day or visit limits) that apply to MH/SUD benefits in any classification must be no more restrictive than the “predominant” quantitative treatment limitations that apply to “substantially all” medical/surgical benefits in the same classification.

Q8: 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 for the benefit categories specified, including for generic drugs, preferred brand drugs, non-preferred brand drugs, and specialty drugs. If the plan's cost sharing values do not conform with the required cost sharing values in the Plans and Benefits Template and the corresponding Standard Plan Option Add-In file, the plan will receive a deficiency and will fail to be considered a Standardized Plan Option. 
    Therefore, issuers should design prescription drug formularies for Standardized Plan Option plans to be able to enter four tiers of prescription drug cost sharing in the Plans and Benefits Template, and each of these four tiers of cost sharing must conform with the required cost sharing values specified in the Notice of Benefit and Payment Parameters for 2023 final rule.

    For example, an issuer offers a non-standardized standard silver plan with the following six-tier formulary in the Prescription Drug Template:
    • Preferred Generic: $15
    • Non-preferred Generic: $25
    • Preferred Brand: $40
    • Non-Preferred Brand: $80
    • Preferred Specialty: $300
    • Non-Preferred Specialty: $400
Instead of creating a new four-tier formulary specifically for its Standardized Plan Options, issuers are permitted to in effect collapse multiple tiers of cost sharing in the Prescription Drug Template into a single tier in the Plans and Benefits Template. For example, an issuer may offer a standard silver Standardized Plan Option with the following six-tier formulary in the Prescription Drug Template:

    • Preferred Generic: $20
    • Non-preferred Generic: $20
    • Preferred Brand: $40
    • Non-Preferred Brand: $80
    • Preferred Specialty: $350
    • Non-Preferred Specialty: $350

This six-tier formulary in the Prescription Drug Template would be translated to the four-tier formulary in the Plans and Benefits Template in the following manner:

    • Generic: $20
    • Preferred Brand: $40
    • Non-preferred Brand: $80
    • Specialty: $350

Standardized Plan Options Add-in File

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

  • Unlike the Plans and Benefits Template Add-In file, you must open the Standardized Plan Option Add-In file, or it will not load into the Plans and Benefits Template automatically. To load the Standardized Plan Option Add-In file, navigate to the add-in file on your 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 and 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 and 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 should now load into the Plans and Benefits Template and appear on the ribbon of the Excel file. 

Q2: Why does the Standardized Plan Option Add-In file populate cost sharing information for the limited cost sharing CSR plan variations?
  • Though CMS did not finalize specific standardized plan designs for the zero cost-sharing and limited cost-sharing CSR plan variations, the Standardized Plan Option Add-In file does populate values for limited cost-sharing CSR plan variations given that the limited cost sharing must match the corresponding Standardized Plan Option cost sharing in the Plans and Benefits Template. Furthermore, while the Standardized Plan Option Add-In file does not populate values for zero cost-sharing plans, the Plans and Benefits Template Add-In file does populate values for zero cost-sharing plans. 
Q3: Is it required to run the actuarial value (AV) output calculator in the Plans and Benefits Template after using the Standardized Plan Option Add-In file?
  • Issuers must run the AV output calculator in the Plans and Benefits Template for all plan variations using the Plans and Benefits Template Add-In file by selecting the "Check AV Calc" button and running the Final AV Calculator. The AV output calculator will overwrite AV Calculator Output Number field with the AV Calculator numbers set forth in the Notice of Benefit and Payment Parameters for 2023 final rule and populated by the Standardized Plan Option Add-In file. 

i The information provided in this guidance is intended only to be a general informal summary of technical legal standards. It is not intended to take the place of the statutes, regulations, or formal policy guidance upon which it is based. This guidance summarizes current policy and operations as of the date it was presented. We encourage readers to refer to the applicable statutes, regulations, and other interpretive materials for complete and current information.

See 45 CFR 146.136. Final Rules Under the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008; Technical Amendment to External Review for Multi-State Plan Program; Final Rule (78 FR 68240); November 13, 2013. See https://www.gpo.gov/fdsys/pkg/FR-2013-11-13/pdf/2013-27086.pdf 

2 The rule divides benefits into six classifications: outpatient, in-network; outpatient, out-of-network; inpatient, in-network; inpatient, out-of-network; emergency services; and prescription drugs. Furthermore, plans can elect to break out the outpatient classification into two sub-classifications for the purpose of the parity analysis: office visits and other outpatient services.

3 See 87 FR 27320.