CMS Releases Exchange Guidance for 2022

The Centers for Medicare and Medicaid Services (CMS) released the first draft of its annual Exchange guidance at the end of November: the proposed Notice of Benefit and Payment Parameters for 2022 (NBPP) and the 2022 Draft Letter to Issuers in the Federally-facilitated Exchanges (Letter) as well as accompanying guidance and timelines.[1] With the change in federal leadership looming, CMS has an especially tight timeline on comments; comments on the Letter are due by December 23rd, and on the NBPP by December 30th.

As always, the NBPP, Letter, and other guidance address key timelines, certification standards, financial parameters, and operational and technical guidance for Exchanges, Qualified Health Plans (QHPs), and premium stabilization programs. Overall, very few changes were made to standards from prior years—though, as always, some tweaks and updates were included.

As required under the Patient Protection and Affordable Care Act (ACA), CMS has proposed increases to the annual limit on cost-sharing for QHPs, including for cost-sharing reduction (CSR) plan variations, based on the proposed 2022 premium adjustment percentage. These proposals are detailed in the table below:

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CMS also released the proposed key dates for the 2022 QHP certification process, which are as follows:

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Likely due to the pending change in federal administration, the proposed guidance also includes some significant changes, both related and unrelated to the Exchange. Following in line with changes made to the Small Business Health Options Program (SHOP) several years ago, as well as portions of the recently-approved Section 1332 Waiver in Georgia, the NBPP proposes allowing Exchanges to eliminate the enrollment function and, instead, approve private entities to conduct direct enrollment, which would be the sole option for Exchange enrollment. This eliminates the central role of the Exchanges as a one-stop shop to compare and enroll in QHPs and receive determinations for financial subsidies, significantly gutting a central part of the ACA.

The NBPP also proposes enshrining the 2018 Section 1332 Waiver guidance into regulations. The 2018 guidance weakened the statutory guardrails that Section 1332 Waivers must meet for approval, making it easier for those guardrails to be considered satisfied by proposed waivers. The NBPP does not make further changes to the rules for Section 1332 Waivers, nor does it make it impossible for the next administration to change the current standards. However, changing the standards will entail a longer process if they are part of regulations, rather than sub-regulatory guidance.

With a new presidential administration incoming, it is very likely that there will be further changes to this year’s regulations, as well as changes previously made to Exchanges, QHPs, and other ACA guidance (similar to what took place with 2017’s Market Stabilization Rule). Even if the regulations and guidance are finalized prior to the President-elect taking office—as was the case in 2017—the new administration can update the regulations or promulgate further regulations to update the Exchange rules.

With that caveat in mind, as we do each year, we have compiled the key changes proposed in the 2022 annual Exchange guidance into a fact sheet—click the thumbnail on the right to view it.

This document highlights changes from prior years’ guidance to assist states in considering whether to submit comments. However, particularly given the impending transition, we encourage you to stay tuned for further updates that will likely include key changes for 2022 and beyond.

Thinking more broadly, states should keep the following areas in mind—as they are likely to be on the radar of the new administration when considering its policy priorities:

  • Reinstituting the requirement that Exchanges facilitate enrollment (if that is eliminated by the NBPP)
  • Strengthening the role of the SHOP, which was narrowed by the 2019 NBPP
  • Reversing changes to the Essential Health Benefit benchmark plan options and process made through the 2018 NBPP
  • Reversing changes that weakened the network adequacy and essential community provider standards through the 2017 Market Stabilization Rule
  • Reversing the expansion of the de minimis variation allowed to the actuarial values for Exchange coverage levels
  • Reinstating the standardized plan that was eliminated in the 2018 NBPP
  • Expanding the Open Enrollment Period that was made shorter through the 2017 Market Stabilization Rule
  • Reversing changes that made Special Enrollment Periods more restrictive, including through the 2017 Market Stabilization Rule
  • Reinstating payments for cost-sharing reductions
  • Reinstating funding for Navigators and outreach and enrollment

Health Policy News will continue to monitor this guidance and update readers on changes once finalized by CMS. If states have any questions on proposed policy changes, please contact us at


[1] Proposed QHP PY2022 Data Submission and Certification Timeline Bulletin; Guidance on Unified Rate Review Timeline: Proposed Timing of Submission of Rate Filing Justifications for the 2021 Filing Year for Single Risk Pool Coverage Effective on or after January 1, 2022; Proposed Key Dates for Calendar Year 2021: Qualified Health Plan (QHP) Data Submission and Certification, Rate Review, and Risk Adjustment; Draft 2022 Actuarial Value Calculator; Draft 2022 Actuarial Value Calculator Methodology

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