ACA Insurers Must Include Mental Health Providers In Plans: CMS

The Centers for Medicare and Medicaid Services will require insurers on the Affordable Care Act exchanges to include substance abuse and mental health providers in their plans, among other things.

  • CMS will require insurers to market their coverage of substance use disorders, mental health treatments, federally qualified health centers and family planning providers by organizing providers into separate categories and instructing insurers to include at least 35% of such clinicians in any given market in their networks.
  • Regulators abandoned their plan to require carriers to standardize how they cover generic, brand and specialty drugs. The agency dropped the plan after facing pushback from insurers saying it would eliminate their ability to tailor formularies. CMS said it will continue to investigate the market implications this proposal.
  • The agency abandoned its proposed plan to require a “meaningful difference” standard among insurers, which would have required plans offered by the same company in the same area and at the same metal level to have a difference in deductibleof more than $1,000.
  • Federally funded navigators can go door-to-door to conduct enrollment and outreach and sign up consumers during their first meeting.
  • Brokers must confirm with customers their income and other personal information before submitting applications. CMS aims to extend the amount of time the Health and Human Services Department has to act on consumer complaints against brokers. Brokers must retain any electronic or telephonic interaction they have with customers for at least 10 years.
  • The user fees insurers must pay to market their products on marketplaces is decreased by nearly 0.5% on both the federal and state marketplaces. Carriers would pay 2.2% premiums for plans sold on the federal marketplaces, and 1.8% premiums for plans sold on state marketplaces.CMS originally sought reductions that were half as much.
  • CMS will update the risk-adjustment data that plans must submit for 2024, and charge insurers a per-member fee for calculating what they owe or are owed under the federal program. The risk-adjustment program requires plans that insure healthier customers to pay into a pool for insurers with sicker and costlier policyholders.
  • The agency will modify the automatic enrollment process for low-income consumers to direct those who qualify for cost-sharing reductions to silver plans with similar provider networks to their current bronze plans.


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