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CMS adopts payment provisions to lower costs in the 2022 marketplace

The rule finalizes a maximum annual limitation on cost-sharing that is $400 below what CMS proposed in November 2020.

Susan Morse, Managing Editor

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The Centers for Medicare and Medicaid Services has adopted new provisions to lower maximum out-of-pocket costs by $400 in the federal health insurance marketplaces in 2022.

The payment notice finalizes a maximum annual limitation on cost-sharing in the ACA market that is $400 below what CMS proposed in November 2020.

CMS filed the Patient Protection and Affordable Care Act: Notice of Benefit and Payment Parameters for 2022 and Pharmacy Benefit Manager Standards today, April 30, that is scheduled to be published on May 5.

This is the second payment notice of the year, since CMS announced it would be finalizing the payment notice in multiple phases. The first 2022 payment notice final rule was released in January 2021. 

CMS said it anticipates additional rulemaking for the 2022 payment notice later this year.


The second 2022 Notice of Benefit and Payment Parameters final rule released today aims to stabilize the insurance market, promote program integrity and reduce regulatory burden, CMS said. It includes several provisions to help consumers more easily distinguish between plan options and increase opportunities to qualify for future special enrollment periods.

The annual payment notice makes regulatory changes in the individual and small-group health insurance markets, and outlines parameters and requirements issuers need to design plans and set rates for the upcoming plan year. The notice also includes regulatory standards to help states, the marketplaces and insurance issuers in the individual and small-group markets better serve consumer needs.

Revised measures establishing parameters for determining insurance affordability and cost-sharing will allow consumers to purchase lower-priced plans. These allow those aged 30 and over to apply for catastrophic coverage (coverage that generally offers lower-priced plans to protect someone from high medical costs).

The calculations will slow the growth rate for cost-sharing, which might otherwise place an undue burden on sicker and lower-income enrollees and, when adopted by the Internal Revenue Service, will also expand eligibility for tax credits to reduce the cost of health insurance premiums for lower-income enrollees.

A number of other provisions will make it easier for consumers to comparison shop for plans and improve support for the Federal Health Insurance Marketplaces, health insurance issuers and other stakeholders who facilitate access to coverage. 


The Biden Administration has promised to strengthen the Affordable Care Act.

During the pandemic, CMS opened a special enrollment period for consumers to sign up for health insurance. This was to get coverage for those who may have lost their employer insurance because of job losses due to the pandemic or any other reason.

CMS today said it plans to expand the opportunities consumers have to sign up for health coverage outside the annual open enrollment period. 

These special enrollment policies will offer greater flexibility for those who need coverage – particularly those communities hardest hit by COVID-19, CMS said. 

An additional 800,000 Americans enrolled in the ACA under the SEP enacted by the Biden Administration.

In his first joint address to Congress Wednesday night, Biden said he wanted to continue to lower premiums and deductibles in the ACA market.


"Families deserve to have access to healthcare coverage that doesn't break the bank. That's why today we're acting to lower consumers' maximum out-of-pocket costs by $400 and why President Biden has a plan to reduce families' healthcare costs for the long run," said Department of Health and Human Services Secretary Xavier Becerra. 

"The ACA and the American Rescue Plan offer a lifeline to coverage for millions who might otherwise be uninsured," said Jeff Wu, CMS Acting Principal Deputy Administrator and Deputy Director for Policy in the CMS Center for Consumer Information & Insurance Oversight.

Twitter: @SusanJMorse
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