Skip to main navigation Skip to main content Skip to footer For Individuals & Families For Medicare For Providers For Brokers Español For Employers: For Employers Medical Savings and Spending Accounts (HRA/HSA/FSA) Wellness, Mental Health, and Behavioral Pharmacy Dental and Vision Cost Control Strategies Supplemental Health Solutions Who We Serve Overview Small Employers (51 - 499) Medium Employers (500 - 2,999) Large Employers (3,000+) Hospitals and Health Systems Higher Education K-12 Education State and Local Governments Taft-Hartley and Federal Membership and Affinity Groups Third Party Administrators Health Insurance for Expats IGO/NGOs Multinational Businesses Why Cigna Overview Industry Insights Overview Informed on Reform Workplace Wellness Consumer-Driven Health Plans Log in to Employer Portal
Home Employers Industry Insights for Employers and Brokers Informed on Reform Health Care Reform NewsACA Final Regulations 2020

Article | April 2019

Final Regulations – 2020 Notice of Benefit and Payment Parameters

On April 18, 2019, the Centers for Medicare and Medicaid Services (CMS) issued final regulations and related guidance on a number of Affordable Care Act (ACA) provisions and related health care topics including out-of-pocket (OOP) maximums, Essential Health Benefits (EHBs), the opioid epidemic, and Exchange updates and reforms. These regulations are generally effective for plan years beginning on and after Jan. 1, 2020.

2020 OOP maximums

The 2020 OOP maximums will increase to $8,150 for individual coverage and $16,300 for family coverage. These coverage limits apply to all non-grandfathered plans, regardless of size or funding type.

Prescription drug cost-sharing

Three prescription drug pricing-related provisions were included in the proposed rule issued on Jan. 17, 2019. Due to concerns submitted by commenters, CMS chose to only include one in the final rule. Beginning in 2020, plans are permitted, but not required, to exclude drug manufacturer coupons from counting toward a covered person’s annual OOP maximum if a medically appropriate generic drug is available. This applies to individual, small group, large group, and self-funded plans, to the extent permitted by state laws.

Essential Health Benefits (EHBs)

Last year’s regulations gave states more flexibility in selecting EHB benchmark plans beginning with the 2020 plan year. Illinois was the only state to make changes for 2020. The deadline for notifying CMS of 2021 benchmark plan changes is May 6, 2019 and May 8, 2020 for the 2022 plan year.

As a reminder, any health plan that covers EHBs must cover these benefits with no annual or lifetime dollar maximums. This includes both fully insured and self-funded employer-sponsored plans.

Opioid addiction

The regulations encourage states to explore future EHB benchmark plan modifications that would be helpful in addressing the opioid epidemic.

They also encourage, but do not require, insurers to cover all four Medication-Assisted Treatment (MAT) drugs for treatment of opioid use disorder. Furthermore, HHS requires that if a plan excludes MAT for opioid use treatment, but covers it for other conditions, the insurer must justify the exclusion and explain how the benefit design is not discriminatory.

Exchange regulations

The final rule also includes a number of provisions that impact the Health Insurance Exchanges effective Jan. 1, 2020. They include:

  • Making a technical change in how subsidies are calculated, which is projected to raise premium costs for some customers and potentially reduce enrollment.
  • Maintaining the practice of “silver loading,” 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. In the proposed rule, CMS asked for input on whether and how it should end the practice beginning in 2021.
  • Creating a new special enrollment period for consumers who are enrolled in individual market coverage off-Exchange who become eligible for subsidies due to a mid-year decrease in income.
  • Reducing the user fee for qualified health plan (QHP) issuers by 0.5% on the Federally Facilitated Exchange and state-based Exchanges using the Federal platform. Since this fee is typically included in premiums, this may result in small premium reductions.
  • Providing greater flexibility related to Navigator duties, removing certain required functions and requiring fewer trainings.
  • Introducing greater flexibility and more oversight for web brokers who facilitate direct enrollment in Exchange plans outside of HealthCare.gov.
  • Updating the risk adjustment program for insurers with high-cost enrollees.

Review the information at these links for additional details:

  • Read the Final Regulations
  • Read the HHS Fact Sheet [PDF]

We encourage you to bookmark Cigna's health care reform website, Informed on Reform, where we continuously update information as it becomes available.


Related Resources

Informed on Reform News Informed on Reform FAQs Informed on Reform

Page Footer

I want to...

Get an ID card File a claim View my claims and EOBs Check coverage under my plan See prescription drug list Find an in-network doctor, dentist, or facility Find a form Find 1095-B tax form information View the Cigna Glossary Contact Cigna

Audiences

Individuals and Families Medicare Employers Brokers Providers

Secure Member Sites

myCigna member portal Health Care Provider portal Cigna for Employers Client Resource Portal Cigna for Brokers

Cigna Company Information

About Cigna Company Profile Careers Newsroom Investors Suppliers Third Party Administrators International Evernorth

 Cigna. All rights reserved.

Privacy Legal Product Disclosures Cigna Company Names Customer Rights Accessibility Report Fraud Sitemap

Disclaimer

Individual and family medical and dental insurance plans are insured by Cigna Health and Life Insurance Company (CHLIC), Cigna HealthCare of Arizona, Inc., Cigna HealthCare of Illinois, Inc., and Cigna HealthCare of North Carolina, Inc. Group health insurance and health benefit plans are insured or administered by CHLIC, Connecticut General Life Insurance Company (CGLIC), or their affiliates (see a listing of the legal entities that insure or administer group HMO, dental HMO, and other products or services in your state). Accidental Injury, Critical Illness, and Hospital Care plans or insurance policies are distributed exclusively by or through operating subsidiaries of Cigna Corporation, are administered by Cigna Health and Life Insurance Company, and are insured by either (i) Cigna Health and Life Insurance Company (Bloomfield, CT); (ii) Life Insurance Company of North America (“LINA”) (Philadelphia, PA); or (iii) New York Life Group Insurance Company of NY (“NYLGICNY”) (New York, NY), formerly known as Cigna Life Insurance Company of New York. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. LINA and NYLGICNY are not affiliates of Cigna.

All insurance policies and group benefit plans contain exclusions and limitations. For availability, costs and complete details of coverage, contact a licensed agent or Cigna sales representative. This website is not intended for residents of New Mexico.

Selecting these links will take you away from Cigna.com to another website, which may be a non-Cigna website. Cigna may not control the content or links of non-Cigna websites. Details