CMS issued the Department of Health and Human Services (HHS) Notice of Benefit and Payment Parameters final rule for 2018 on Friday December 16, 2016, establishing standards for insurers and each health insurance marketplace for the 2018 plan year.

These final regulations, effective for plans and plan years beginning on and after January 1, 2018, include updates to the risk adjustment program, simple choice health plan options and initiatives to limit misuse of special enrollment periods, among others.

Among the provision updates that primarily impact the individual and small group markets, the final regulations also include an increase to the consumer out-of-pocket maximum, up to $7,350 for individual coverage and $14,700 for family coverage ($7,150 for individual, $14,300 for family in 2017). The 2018 annual out-of-pocket maximum increase will directly impact large group health plans.

CMS considered but did not adopt the following changes:

  • to augment the model for specific services such as habilitative or pediatric dental services;
  • to allow for adjustments for wellness incentives;
  • to recognize urgent care cost sharing;
  • expanding the drug tiers available under the calculator;
  • to allow for beginning mental health/behavioral health and substance abuse service cost sharing or deductible/coinsurance after a set number of visits or copayments; and
  • to permit separate AV calculations for family plans.

For additional details, please see the HHS Fact Sheet that summarizes the 2018 regulations.