The Department of Health and Human Services (HHS) released part two of the 2022 Notice of Benefit and Payment Parameters (NBPP) on April 30, 2021. The NBPP is the annual rule that governs the Affordable Care Act (ACA) marketplaces and insurance reforms. The update most pertinent to group health plans (GHPs) in the part two update of the NBPP is the revised maximum out-of-pocket costs to plan participants. HHS and Centers for Medicaid and Medicare Services (CMS) plan to issue additional rulemaking to finalize the remaining proposed provisions of the 2022 NBPP later this year.
HHS Sets the plan year annual limitation on cost-sharing annually.
The annual limitation on cost-sharing is the maximum amount of out-of-pocket expenses that a plan can require enrollees to pay for covered healthcare services and items. After a plan participant, or participants on an other than self-only plan, meet this limit, the plan will usually pay 100% of the allowed amount for covered services. A plan enrollee’s cost share or out-of-pocket expenses can include their deductible, coinsurance and copayments. The annual limitation on cost-sharing is also described as the out-of-pocket maximum/limit (OOPM). This limit does not include premiums, balance billed charges, penalties you may have to pay or healthcare that the plan does not list as a covered item or service.
The rule finalizes that the 2022 OOPM is $400 below what CMS previously proposed as the OOPMs for the 2022 plan year.
HHS sets the OOPM based on the premium adjustment percentage index (PAPI). Initially, HHS calculated the 2022 PAPI using National Health Expenditure Accounts (NHEA) projections and estimates of private health insurance premiums. However, the Agency received comments from interested parties that suggested using the measure to calculate the OOPM for benefit years 2015 through 2019. Consequently, HHS based its final calculation of the 2022 OOPM using the NHEA projections of average per enrollee employer-sponsored insurance (ESI) premiums.
The OOPMs (for self-only and other than self-only coverage) for 2022 increased slightly from 2021 OOPMs.
The OOPMs for 2022 are $8,700 for self-only coverage and $17,400 for other than self-only coverage (up from $8,550 and $17,100, respectively, for 2021). Self-only coverage means an individual coverage or employee-only plan. Other than self-only, coverage encompasses individual plus dependent plans, including employee or individual plus spouse or domestic partner plans and family plans. Compared to the 2021 OOPMs, the 2022 OOPM is an increase of $150 for individual coverage and $300 for family coverage. The final 2022 reduced OOPM for eligible enrollees with incomes between 100% and 200% of the federal poverty level (FPL) is $2,900 for individual coverage and $5,800 for other than individual coverage. The 2022 reduced annual limitation on cost-sharing for eligible enrollees with incomes above 200% and through 250% FPL is $6,950 for individual coverage and $13,900 for other than individual coverage.
Find a copy of the 2022 NBPP for more information. Interested individuals can read the 2022 NBPP Final Rule Part Two Fact Sheet for additional information and explanation. To stay up to date about the final 2022 NBPP rules, follow the CMS news updates at cms.gov/newsroom, or sign up for CMS news via email.
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Compliance Manager – Atlanta, GA