Notice of Benefit and Payment Parameters (NBPP) final rule eases access to OT

The Centers for Medicare & Medicaid Services (CMS) released the annual Notice of Benefit and Payment Parameters (NBPP) final rule on April 28, 2022. The NBPP is the annual regulation governing the Marketplaces created by the Affordable Care Act. CMS finalized changes related to consumer cost sharing, provider network strength, and the scope of covered benefits that will decrease barriers to occupational therapy (OT) services.

Standardized plans with lower cost sharing for OT

In 2023 CMS will require Marketplace insurers to offer standardized plans, which reduce the variables to compare from plan to plan by offering identical deductibles, annual cost-sharing limits, and copayments (or coinsurance) for a key set of health services. The plan design has lower out-of-pocket costs for OT than prior iterations of standardized plans, which were last offered in 2018.

Key features of the 2023 standardized plans:

• Cost sharing is the same for OT and primary care visits. For example, “silver”-level standardized plans have $40 copays for primary care and occupational, physical, and speech therapy.

• The deductible does not apply to OT services, which means that insurance pays for OT visits right away (when the deductible applies to a service, the consumer is responsible for 100% until the deductible amount is met and insurance begins to pay).

• There is a copay (fixed dollar amount), not coinsurance (a percentage of the cost of the service), for OT services.

• No visit limits for any benefit categories.

Compared with the earlier standardized designs, which featured coinsurance subject to the deductible for OT, reducing cost sharing for OT services will make it more likely that people will use the OT benefits their plans cover. With a $5,800 deductible for a “silver” plan, exempting OT from the deductible will help make it an accessible service, rather than a benefit on paper only. And reasonable, predictable copays at parity with primary care will benefit OT recipients who need frequent visits to attain, regain, or maintain skills and functioning for daily living.

Although insurers will be required to offer standardized plans, non-standardized options with more flexible benefit designs will still be available.

New network adequacy standards for OT

The NBPP reinstates and expands network adequacy measures that were rescinded in 2018, adding OT and a handful of other provider types to the list of specialties with federally enforced time and distance requirements. For example, in a large metro county, plans will have to prove that 90% of their enrollees can reach an in-network OT provider within 10 miles and 20 minutes. The full time and distance standards are listed in the 2023 Final Letter to Issuers in the Federally-facilitated Exchanges.

Banning benefit substitution between EHB categories

CMS is eliminating the state option to allow health plans to substitute benefits between categories of essential health benefits (EHBs). EHBs are the 10 core categories of services that ACA plans must cover. This change will make it less likely that plans will opt to reduce OT services in order to increase other services, or make other benefit substitutions that would cut services needed by people with disabilities or chronic conditions and replace them with benefits meant to attract healthier enrollees.

Promoting nondiscriminatory, evidence-based benefit design

In the draft NBPP, CMS proposed a new framework for enforcing nondiscrimination in benefit design by adding an explicit requirement that benefit limitations and coverage requirements be based on current clinical evidence. A plan that is free from discriminatory benefit design is one that is “clinically based, that incorporates evidence-based guidelines into coverage and programmatic decisions and relies on current and relevant peer-reviewed medical journal article(s), practice guidelines, recommendations from reputable governing bodies, or similar sources,” according to the proposed rule. AOTA’s practice guidelines were specifically cited as a “relevant and credible” source of the kind of clinical evidence that should form the basis of nondiscriminatory benefit design.

The final rule retains the clinical basis requirement, but it does not include the proposed regulatory text that would have required plans to prove they relied on practice guidelines, peer-reviewed journals, etc. While the language mentioning AOTA’s practice guidelines was not finalized, our evidence-based practice resources were acknowledged in an important annual regulatory document, raising awareness of AOTA’s resources for practice— and policy— improvement.