Posted in: Government Outreach


January 30, 2023

Ms. Chiquita Brooks-LaSure, Administrator
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-9899-P
P.O. Box 8016
Baltimore, MD 21244-8016

Via Electronic Submission at

RE: CMS-9899-P; RIN 0938-AU97

Dear Administrator Brooks-LaSure,

The Accreditation Association for Ambulatory Health Care, Inc. (AAAHC) appreciates the opportunity to submit comment to the Centers for Medicare & Medicaid Services (CMS) regarding the recently proposed Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2023.

The AAAHC is a private and independent 501(c)(3) non-profit accreditation organization formed in 1979. Since its inception, AAAHC has promoted a voluntary, consultative, peer-based, and educational survey process to advance patient care. These values hold true today, as embodied in our mission statement: Improving health care quality through accreditation. With more than 6,600 accredited organizations in a variety of ambulatory health care settings, AAAHC is a leader in developing Standards to advance and promote patient safety, quality care, and value for ambulatory health care through its accreditation programs, education, research, and other resources. Currently, more than 30 health plans are committed to excellence through AAAHC accreditation.

AAAHC is a recognized health plan accreditor through several federal and state agency regulatory agencies including the CMS Center for Consumer Information and Insurance Oversight (CCIIO) for Qualified Health Plans (QHPs), the U.S Office of Personnel Management (OPM) for Federal Employee Health Benefits plans (FEHBs), the Florida Agency for Health Care Administration (AHCA) for Health Maintenance Organizations (HMOs) and prepaid health clinics, and various state health insurance oversight agencies in Arizona, Georgia, Illinois, Kansas, Louisiana, Minnesota, Missouri, Nevada, New Mexico, Oklahoma, and Pennsylvania. AAAHC also provides accreditation services to the United States Coast Guard ambulatory health centers, Federally Qualified Health Centers that receive funds from the United States Health Resource and Services Administration (HRSA), and Indian Health Services (IHS) funded health centers. Other AAAHC-Accredited Organizations include Ambulatory Surgical Centers, Community Health Centers, Indian Health Centers, Student Health Centers, Medical Group Practices, and Office-based Surgery Centers.

The AAAHC founding principles are grounded in providing patients with options amongst health care services and the opportunity to choose the services that best fit their needs. Federal agency responsibilities set forth in Executive Order 14036: Promoting Competition in the American Economy establishes HHS must ensure every American’s ability to choose health insurance plans that meet their needs through improved competition and consumer choice. E.O. 14036 requires that all federal agencies consider the influence their regulations, particularly licensing regulations, will have upon industry competition and concentration. We are concerned that certain provisions within this proposed rule may be so burdensome to QHP issuers, resulting in the unintended consequence of eliminating options available to patients. The Affordable Care Act (ACA) and the Health Insurance Exchange were adopted to increase consumer choice and access to health care, and we urge HHS to keep these goals in mind, especially as it calculates the burden of this proposal. Each proposal compounds upon the next, creating a greater burden than perceived in a burden calculation that separately calculates the cost of individual proposals.

General Statement of Support

AAAHC would like to state its support of the HHS efforts to:

  • simplify and streamline plan options for consumers through removal of the requirement for a non-expanded bronze level standardized plan, implementation of specified prescription drug tier requirements, and limitation on the number of non-standardized plans that may be offered through the Federal platform,
  • allow additional variation for adult dental and adult vision benefits,
  • impose a meaningful difference standard, and
  • standardize the age calculation method and require the use of guaranteed rates for stand-alone dental plans.

Specific Feedback to ICRs

III. Provisions of the Proposed Regulations

C. Part 156—Health Insurance Issuer Standards Under the Affordable Care Act, Including Standards Related to Exchanges

4. Non-Standardized Plan Option Limits (§ 156.202)

In the proposal, HHS recognizes the existence of alternative methods for the facilitation of more meaningful consumer choice other than standardization requirements, such as limiting the number of allowable plans an issuer may offer by metal level or through the creation of meaningful difference Standards. AAAHC believes that implementing either or both alternatives provides a greater likelihood of creating increased meaning for consumers without necessarily increasing the number of consumer plan offerings or the level of burden faced by issuers.

6. Plan and Plan Variation Marketing Name Requirements for QHPs (§ 156.225)

HHS proposes to add a new paragraph (c) to § 156.225 to require that QHP plan and plan variation marketing names include correct information, without omission of material fact, and do not include content that is misleading, requiring all information included in plan and plan variation marketing names that relates to plan attributes to correspond to and match information that issuers submit for the plan in the Plans & Benefits Template, and in other materials submitted as part of the QHP certification process. In support of this requirement, AAAHC Standards require that members be informed upon enrollment (and periodically thereafter) of covered benefits and services, coverage and care exclusions/restrictions, and applicable fees, copays, and payments. AAAHC Standards also require an organization’s governing body to ensure compliance with all contractual obligations, laws, and regulations.

8. Essential Community Providers (§ 156.235)

HHS proposes to expand access to care for low-income and medically underserved consumers by strengthening ECP standards for QHP certification. HHS proposes to create two standalone ECP categories for Mental Health Facilities and Substance Use Disorder (SUD) Treatment Centers. Additionally, HHS proposes to add Rural Emergency Hospitals (REHs) as a provider type in the Other ECP Providers ECP category. Furthermore, HHS proposes to require QHPs to contract with at least 35 percent of available FQHCs that qualify as ECPs in the plan’s service area and at least 35 percent of available Family Planning Providers that qualify as ECPs in the plan’s service area. Finally, HHS proposes to revise § 156.235(a)(2)(i) to clarify that these proposed requirements would be in addition to the existing provision that QHPs must satisfy the overall 35 percent ECP threshold requirement in the plan’s service area. We note that HHS would retain its current overall ECP provider participation standard of 35 percent of available ECPs based on the applicable PY HHS ECP list, including approved ECP write-ins that would also count toward a QHP issuer’s satisfaction of the 35 percent threshold. HHS is proposing that only two ECP categories, FQHCs and Family Planning Providers, be subject to the additional 35 percent threshold in PY 2024 and beyond.

AAAHC supports changes to the HHS network adequacy requirements for QHPs. Our Health Plan Standards require that an adequate network of providers and facilities be maintained and specifies that any contractual network adequacy requirements be met. AAAHC Standards also require regular assessment of both member and network provider satisfaction, including an analysis of results and the application of interventions to improve future results. Member satisfaction assessments under AAAHC Standards must incorporate network satisfaction, inclusive of the adequacy of the plan’s provider network, provider availability, and ability to access care.

9. Termination of Coverage or Enrollment for Qualified Individuals (§ 156.270)

a. Establishing a Timeliness Standard for Notices of Payment Delinquency

HHS proposes to revise § 156.270(f) to require issuers to send notice of payment delinquency promptly and without undue delay. To help ensure that notices are sent in a timely and uniform manner, HHS also believes it would be important to specify the number of days within which the issuer must send notice from the time an enrollee becomes delinquent on payment, while also recognizing that issuers have a variety of practices for sending delinquency notices.

AAAHC Health Plan Standards require that each organization have protocols for the handling of premium non-payment, including member notification of termination or potential termination of coverage. AAAHC supports standardization of member notification requirements across QHPs and believes that ensuring receipt of member notifications within a reasonable time to procure and remit payment is necessary to support continuous consumer access to care. In the development of a payment delinquency notification standard, AAAHC recommends that HHS communicate with currently certified QHPs to determine if a reasonable industry standard exists related to the timing of member payment delinquency notifications.