Patient Protection and Affordable Care Act – Benefits and Payment Parameters for 2023

The Patient Protection and Affordable Care Act, also known as Obamacare, signed into law on March 23, 2010 has had a series of rules and regulations published under its wing. The CMS-9922-F in 2020, and the CMS-9906-F in 2021 are a few regulations under this act.

In January of 2022, the HHS proposed amendments to certain regulations prohibiting discrimination in health insurance coverage, design and implementation of health plans to further ensure that there exists no room for discrimination. The CMS released the final rule taking into account the comments received on the proposal past April, 2022 as part of the Patient Protection and Affordable Care Act – HHS Notice of Benefit and Payment Parameters for 2023.

The document is over 600 pages long, and we put in some diligent efforts to combine it together so that you get the complete information at one place. Here is the summary of the latest final rules published under the Patient Protection and Affordable Care Act.

The Final Rule Summed Up

  • To strengthen and clarify network adequacy standards, the HHS has finalized that they will be expanding the provider’s specialty list by including county level standards, for time, distance, and wait time. The details of the standards will be provided in the future guidelines.
  • These are some of the scenarios, outlined by the HHS, which would be discriminatory against an individual, based on their health conditions: –
    • Limiting the benefits of services such as Hearing Aid, Autism Spectrum Disorder (ASD), and Infertility Treatment Coverage, as mandated in certain states for persons over a certain age, when it is clinically effective.
    • Limiting coverage for routine foot care for patients who have diabetes, and excluding patients with other underlying causes associated with metabolic, neurologic, or peripheral vascular disease, from foot care coverage.
    • Placing drugs for chronic health conditions in the high-cost prescription drug tier, making it difficult for most people to access it.


  • Redefining the Essential Health Benefits (EHB) nondiscrimination policy, the HHS has stated that, the issuer can’t discriminate against an individual, by their age, expected length of life, present or predicted disability, degree of medical dependency, quality of life, or any other health condition. Under EHB, the HHS mentions that the issuer should not discriminate based on race, color, national origin, disability, age, or sex.
  • The user fee rate of 2.75 percent of monthly premiums charged by the issuer, when enrollment is through a Federal Facilitated Exchange, remains the same.
  • Availability of health insurance coverage to the Group or Individual Health Insurance Markets must not discriminate against individuals or employers
    • When they owe past-due premiums for coverage from the same issuer or another issuer in the same controlled group.
    • Based on sexual orientation and gender identity.
  • Enrollee-level EDGE data 2017, 2018, and 2019 will be used to recalibrate the 2023 risk adjustment models as proposed.
  • Removal of the current severity illness factors in the adult models and replacing them with new severity and transplant indicators that interacted with the HCC count factors in the adult and child models.

[Related Link]: Payers, are you compliant with the latest rules and regulations? If not, have a look. 

Collection of Information Requirements

  • The flexibility for a State to request reductions to Risk Adjustment State transfer payments for the 2024 benefit year and beyond is annulled. Although, the States that have previously submitted State flexibility requests should be considered as an exception and be allowed to continue with the requested reductions for the year 2024 benefit year.
  • 5 new data elements from issuers’ EDGE servers – ZIP Code, race, ethnicity, ICHRA indicator, and subsidy indicator must be taken into account for distributed and risk adjustment data submission to OMB starting in 2023.
  • States that have their own insurance exchanges should conduct pre-enrollment eligibility verification for special enrollment periods at the option of the exchange. The exchanges should verify special enrollment period eligibility for the most common enrollment period type and the loss of minimum essential coverage.
  • The HHS will provide State Exchanges with the pre-sampling data request for risk adjustment coverage, which State Exchanges will complete and return to the HHS. Both the pre-sampling data request and the requested source data should be in an electronic format.
  • The HHS has increased its participation standard from 20% to 35%  for ECP (Essential Community Provider) Provider for QHP.
  • Cost Sharing Reduction data submission is mandatory for those issuers that received Cost Sharing Reduction payments from the HHS for any part of the benefit year and voluntary for other issuers.
  • To calculate MLR, only the incentives, which are given to providers based on a clearly-defined and documented objective and improvement, can be considered. Also, in the numerator of MLR calculation, Health Plans can only take into consideration of expenditures, which are explicitly related to tasks performed to improve the health care quality for members, under Quality Improvement Activity (QIA) expenses for reporting.

 [Have a Look]: Don’t miss out on FHIR requirements for Payers 

In Closing 

Now, that we have summarized the rule, it is best for you as an issuer to stay updated on all fronts and ensure implementation of all that’s required by this rule. If and when the HHS releases more updates, we shall be ready with the summarized version.

[Also Read]: Looking for Interoperability and Burden Reduction proposals?  

At Nalashaa we have healthcare experts who are well versed with the adjustments and modifications healthcare IT systems need to  adhere to the compliance standards. Get in touch with our IT experts for healthcare compliances services for IPA, TEFCA, and for Interoperability and Burden Reduction.

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Shireen Noushad

Shireen Noushad

Currently, trying to navigate through the ocean of Healthcare IT systems, processes, and workflows. Passionate about writing, and stringing together words in the simplest of ways for a better reading experience and easier comprehension.

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