CMS Final Regulations


On April 18, 2019, the Centers for Medicare and Medicaid Services (CMS) issued final regulations on the 401-page rule as well as related guidance on a number of Affordable Care Act (ACA) provisions and related health care topics.


The final rule has some routine updates for exchange plans, but also some changes that could affect enrollees for the 2020 coverage year.




CMS Final Regulations Take Away

  • Out-of-Pocket (OOP) maximums increasing from $7,900 to $8,150 for individual plans and from $15,800 to $16,300 for family plans.

  • Established a special enrollment period for U.S. residents who become newly eligible for ACA subsidies outside of the regular open enrollment period.

  • Exchange insurers will be allowed (but not required) to make mid-year changes to their plans' drug formularies in order to incentive the use of generic drugs. This is called the copayment accumulator program whereas drug manufactures coupons can be made exempt for brand-name drug over an available generic version.

  • Premium assistance reducing for lower-income enrollees by 0.07 percent. Under the new ruling CMS will base the calculation on a blend of individual market and employer-sponsored plan premiums for the 2020 coverage year.

  • "Silver-Loading" still allowed. This is markeplace practice which allows insurers to load premium increases into silver-level Exchange plans to make up for the loss of cost-sharing reduction (CSR) payments. Silver loading also increases subsidy amounts available to eligible enrollees in those plans.

  • Opioid epidemic addressed to encourage (but not require) states to explore future EHB benchmark plan modifications for insurers to cover all four Medication-Assisted Treatment (MAT) drugs for treatment of opioid use disorder.

  • CMS allowing states more flexibility in selecting Essential Health Benefits (EHB) benchmark plans for the 2020 plan year. The ACA defines EHBs by referencing a list of ten categories of items and services that constitute EHBs. The ten categories of EHBs are:

  1. Ambulatory patient services;

  2. Emergency services;

  3. Hospitalization;

  4. Maternity and newborn care;

  5. Mental health and substance use disorder services, including behavioral health treatment;

  6. Prescription drugs;

  7. Rehabilitative and habilitative services and devices;

  8. Laboratory services;

  9. Preventive and wellness services and chronic disease management; and

  10. Pediatric services, including oral and vision care.


These regulations are generally effective for plan years beginning on and after

January 1, 2020. Want to learn more. Read the HHS Fact Sheet!


This Associated Release is for general informational purposes only. While we have attempted to provide current, accurate and clearly expressed information, this information is provided "as is" and AJM Associates, Inc. makes no representations or warranties regarding its accuracy or completeness. The information provided should not be construed as legal or tax advice or as a recommendation of any kind. External users should seek professional advice from their own attorneys and tax and benefit plan advisers with respect to their individual circumstances and needs.

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