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Are You Ready for Measure Changes?


Changes are coming to the Affordable Care Act in 2023. The Department of Health and Human Services (HHS) is making these changes to expand access to high-quality, affordable healthcare coverage.

The open enrollment period begins November 1, 2022. In this blog, we’ll explore the upcoming changes so that your organization can be better prepared to help both new and current patients.

More Standard Plan Options

This rule has been implemented to help simplify the customer shopping experience by creating standardized plan options for issuers providing Qualified Health Plans (QHPs). Out-of-pocket limitations, deductibles, and cost-sharing features will be standardized, enabling consumers to compare other attributes such as...

• Premiums

• Provider networks

• Prescription drug coverage

• Quality ratings

These new plan options offer increased access to coverage before consumers meet their deductibles. Also included are easy-to-follow cost-sharing structures, making it easier for patients to understand the financial commitment they’re making with their choice in a plan. Those offering QHPs must provide plan options at every network type and every metal level—Bronze, Silver, Gold, and Platinum. Following the goal of accessibility, each plan will be displayed differently on

New Network Adequacy Requirements

This rule was designed to ensure that patients have access to the right provider at the right time—and in an accessible location. QHPs will now be required to guarantee that certain classes of providers are available within the necessary time and distance parameters. Examples of this include...

• A QHP will be required to ensure that its provider network includes a primary care provider within ten minutes and five miles for consumers in a large metro county.

• QHPs must ensure that their providers meet minimum wait time standards.

• Routine primary care appointments must be available within 15 business days of a patient’s request.

Additionally, HHS will review specialty providers for time and distance, including emergency medicine, outpatient clinical behavioral health, pediatric primary care, OB/GYN care, and urgent care.

Boosting the Value of Coverage for Consumers

Metal coverage levels for non-grandfathered individuals and small group market plans will be expanded. Some plans will likely have to increase the generosity of their coverage. Importantly for consumers, this will drive the cost of their care down. Consumers will also be able to compare plans at the various coverage metal levels and easily distinguish between said offerings.

Improving Access & Removing Barriers to Coverage

Thanks to the HHS’s efforts to redefine the CMS nondiscrimination policy, this rule works to protect consumers from discriminatory practices related to the coverage of essential health benefits (EHB). A benefit design that limits coverage for an EHB based on a protected classification (age, health condition, race) must be clinically based to be considered nondiscriminatory. Otherwise, it must be changed to allow improved access to care for users.

Aid for Essential Community Providers

Plan Year (PY) 2023 and beyond will increase the Essential Community Provider (ECP) threshold from 20% to 35% of available ECPs in each plan’s service area. The higher ECP threshold will boost access to providers for consumers who are either low-income or medically underserved.

View the final rule here.

Has your health plan been adjusted to meet these new requirements? Enhanced Medication Services can help ensure your organization—staff and patients alike—is prepared for 2023. Our network of community pharmacists engages patients directly through our fully-integrated clinical services application. In concert with our community pharmacies, our team of pharmacists and technicians provides an advanced, end-to-end solution for medication management programs. Contact us today to learn more!

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