HHS Notice of Benefit and Payment Parameters for 2022 and Pharmacy Benefit Manager Standards


The National Health Council (NHC) appreciates the opportunity to provide comments on the Centers for Medicare and Medicaid Services’ (CMS) proposed rule on the Benefit and Payment Parameters for 2022 under the Patient Protection and Affordable Care Act (the Proposed Rule). 

Created by and for patient organizations 100 years ago, the NHC brings diverse organizations together to forge consensus and drive patient-centered health policy. We promote increased access to affordable, high-value, sustainable health care. Made up of more than 140 national health- related organizations and businesses, the NHC’s core membership includes the nation’s leading patient organizations. Other members include health-related associations and nonprofit organizations including the provider, research, and family caregiver communities; and businesses representing biopharmaceutical, device, diagnostic, generic, and payer organizations. The following is our specific response to the details of the proposed rule. 

Since enactment and implementation of the Patient Protection and Affordable Care Act (PPACA), the NHC has recognized that its long-term viability depends on the stability of the individual health plan marketplaces and meaningful outreach, engagement, and communication throughout the enrollment processes. We continue to support policies that promote market stability while aligning with our primary commitment to ensuring that individuals with chronic conditions and disabilities have access to affordable, high-value, sustainable health care. Our comments, therefore, focus on ensuring that all Americans, particularly those with chronic diseases and disabilities, can access the health care they need at a cost they can afford. 

The COVID-19 pandemic has reinforced the societal imperative that all people need access to adequate and affordable health insurance coverage. The Centers for Medicare & Medicaid Services (CMS) has, since the early months of the COVID-19 Public Health Emergency (PHE), focused its efforts and expertise on ensuring that our health care system has the tools and flexibilities needed to respond to the unprecedented demands of the pandemic. While the availability of vaccines and new treatment modalities offer real hope that resolution of this PHE is in sight, uncertainties and challenges remain with respect to the short- and long-term impact of the pandemic on employment, health, and access to health coverage. It is, therefore, more important now than ever that future coverage under the PPACA align with three overarching principles: 

  • Health care must be adequate. Health care coverage should cover treatments patients need, including the services in the essential health benefit package; 
  • Health care should be affordable. It should enable patients to access the treatments they need to live healthy and productive lives; and 
  • Health care should be accessible. Coverage and enrollment should be easy to understand, not pose a barrier to care, and benefits should be clearly defined. 

As CMS considers the finalization of policies related to the 2022 PPACA plan year, we urge it to prioritize the financial, physical, and mental health of the American people ensuring that quality health insurance coverage is adequate, equitable, affordable, and accessible. Specifically, the NHC: 

  • Supports CMS’ proposed amendments to the special enrollment period policy and offers recommendations to strengthen enrollee access to coverage that best suits their needs; 
  • Urges a special enrollment (SEP)- eligibility-determination approach that reflects and responds to determination errors over a pre-set 75 percent standard; 
  • Opposes CMS’ proposal to reduce marketplace user fees; 
  • Opposes changes to the Premium Adjustment Percentage Index (PAPI) and Maximum Annual Limitation on Cost-Sharing, also known as maximum out-of-pocket(MOOP), that would result in financial burdens for patients; 
  • Supports CMS’ proposals to ensure calculations of medical loss ratio (MLR) exclude drug rebates and price concessions, and to facilitate transparency through pharmacy benefit manager (PBM) reporting requirements; 
  • Strongly urges CMS to withdraw its proposal to permit states to implement Direct Enrollment mechanisms without submitting an application for a Section 1332 waiver; 
  • Opposes CMS’ proposed codification of the 2018 guidance interpreting Section 1332 guardrails; and 
  • Urges CMS to return to its earlier position on Copay Accumulators and Maximizers to distinguish between products with and without generic competition. 

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