The 2019 Final Notice of Benefit & Payment Parameters

The Department of Health and Human Services (HHS) Notice of Benefit and Payment Parameters (NBPP) for 2019 final rule was released on April 9, 2018. It has been a rocky road since the beginning for the Affordable Care Act (ACA). Over the past few years, the healthcare industry has been struggling to find balance in order to provide affordable healthcare for all. Many issuers have opted not to offer Qualified Health Plans (QHPs) in order to avoid negative financial repercussions due to market unpredictability. At its highest, there were 252 issuers participating on the Federally-Facilitated Marketplace (FFM) in 2015. This year, that number has decreased to 132 issuers.

The ACA has been a target since the Trump administration took office. In the beginning, there was much focus on repealing and replacing Obamacare. Through natural progression and understanding of the ACA, the focus of healthcare quickly shifted from repealing Obamacare to eliminating unnecessary processes. A keen eye was focused on specific grey areas of regulation as an easy target to make change. Cost-sharing reduction (CSR) quickly became a focus since it is not fully articulated in the ACA in comparison to its intent for the market. Additionally, the individual mandate also became a target. Specific focus on areas like this was an attempt to slowly dismantle the ACA effort. Although it has been a spotty year with many twists and turns for the ACA, the 2019 NBPP takes a holistic, high-level view of the areas throughout the ACA that need to be enhanced in an effort to show forethought and direction for the future. The 2019 NBPP highlights the Trump administration’s goals for healthcare, which are outlined as the following:

  • Increasing flexibility
  • Improving affordability
  • Strengthening program integrity
  • Empowering consumers
  • Promoting stability
  • Reducing unnecessary burdens

These goals provide an overall direction of the areas within the ACA that need specific attention in order to help refine and pave the way to achieving a better healthcare system long term. The manner in which success is measured for each of these goals is still questionable as to whether it will provide what the market needs in order to stabilize and advance growth.

As originally proposed in the 2019 NBPP released on October 27, 2017, HHS is looking to migrate a lot of the administrative burden and decision-making to the states. The ACA will begin to have more of a Medicaid feel as opposed to Medicare. The final rule grants states more control over Essential Health Benefits (EHB) and issuer oversight. Some highly impactful changes finalized in the 2019 NBPP are as follows:

  • States will receive substantially more options when selecting an EHB-benchmarking plan
  • States will have an expanding role in the QHP certification process
  • Standardized plans offered and encouraged through the Marketplace for 2017 and 2018 will not be encouraged for 2019 or displayed on
  • Elimination of requirements for State-Based Marketplaces utilizing the Federal Platform (SBE-FPs)
  • Elimination of meaningful difference requirements for QHPs
  • Allowing Navigator programs more flexibility
  • Advance Premium Tax Credit (APTC) eligibility verification processes established
  • Risk adjustment methodology enhancements
  • HHS-Risk Adjustment Data Validation (RADV) requirement updates

Risk adjustment is one of the “3 R’s” that was initially implemented to cause stability in the market. This stabilization program, along with reinsurance and risk corridor, ended up being the root of much controversy as one-by-one Consumer Operated and Oriented Plans (CO-OPs) and health plans with small market share throughout the country struggled to remain solvent. As part of the 2019 NBPP final rule, new parameters will be added to the HHS-operated risk adjustment methodology in an effort to increase accuracy. Such enhancements for 2019 are as follows:

  • Recalibrating the HHS-risk adjustment model using blended coefficients from the 2016 EDGE server submissions and 2014/2015 MarketScan® data.
  • Removal of two-severity-only drug classes, RXC 11: Ammonium DE toxicants and RXC 12: Diuretics, Loop and Select Potassium-Sparing from the adult risk adjustment model.
  • States may request up to a 50% reduction in risk adjustment payment transfers where HHS operates the risk adjustment program.

There are quite a bit of impactful changes interwoven throughout this final rule. Gorman Health Group teams are diligently reviewing the 2019 NBPP final rule to highlight changes and market impact in a forthcoming white paper. Stay tuned!

Also released on April 9, 2018, were the following:

  • Final Annual Issuer Letter
  • New Guidance expanding hardship exemptions
  • Transformational Policy extended for another year
  • Enhanced eligibility validations for recipients of the APTC



Registration is open for the Gorman Health Group 2018 Forum, April 25-26, 2018, at the Red Rock Resort ideally located near the Red Rock Canyon in Las Vegas. Download our agenda here.

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