The Centers for Medicare & Medicaid Services (CMS) this week released the HHS Notice of Benefit and Payment Parameters (Payment Notice) for 2025 Proposed Rule, which outlines potential changes to the Affordable Care Act (ACA) marketplaces and requirements for those who help marketplace consumers.
The proposed rule also suggests changes that impact the Medicaid program, Children’s Health Insurance Program (CHIP), and the Basic Health Program (BHP). If finalized, the changes would further the White House’s goals of advancing health equity by addressing the health disparities that underlie the health system, CMS said in a fact sheet.
“The proposals build on the Affordable Care Act’s promise to expand access to quality, affordable health coverage and care by increasing access to health care services, simplifying choice, and improving the plan selection process, making it easier to enroll in coverage, enhancing standards and guaranteed consumer protections, reinterpreting the authority to access certain data through Medicaid, CHIP, and Marketplace Hub services, and strengthening markets," CMS said.
The proposals would:
Set network adequacy standards: For plan years beginning on or after January 1, 2025, CMS proposes that state marketplaces and state-based exchanges have network adequacy standards that are at least as strict as the time and distance measure of provider access that are required for federal marketplaces.
Allow for routine adult dental services: CMS said it wants to remove regulatory and coverage barriers and allow states to add the benefits as essential health benefits. This would mean states could improve adult oral health and overall health outcomes, which could help reduce health disparities and advance health equity since these health outcomes are disproportionately low among marginalized communities.
Gives states flexibility in determining financial eligibility for Medicaid: CMS proposes to allow states to target income and/or resource disregards at discrete individuals in the same Medicaid eligibility group, provided the targeting criteria are reasonable. This would provide states with the ability to achieve targeted expansions of Medicaid coverage, in contrast to the all-or-nothing approach required by the current regulation, CMS said.
Makes minor updates to standardized and non-standardized plan options: CMS aims to follow the approach established in the 2024 Payment Notice for standardized plan option metal levels and continue the approach for standardized plan options finalized in the 2023 and 2024 Payment Notices. It proposes to make only minor updates to the plan designs for 2025, such as modifying the maximum out-of-pocket and deductible values, to ensure these plans have actuarial values for each metal level.
The agency also would allow issuers to offer additional non-standardized plan options beyond the two-plan limit for PY 2025 and subsequent years if they demonstrate that these additional plans have reduced cost sharing of 25 percent or more for benefits pertaining to the treatment of chronic and high-cost conditions, relative to an issuer’s other non-standardized plan offerings in the same product network type, metal level, and service area.
Align effective dates of coverage: For ease of consumer experience and to prevent coverage gaps for consumers transitioning between different marketplaces or from other insurance coverage, CMS proposes that consumers who select and enroll in a qualified health plan (QHP) during a special enrollment period with a regular coverage effective date receive coverage beginning the first day of the month after the consumer selects a QHP.
Establish marketplace call center standards: CMS would require that all marketplace call centers provide consumer access to a live call center representative during a marketplace's published hours of operation. These representatives would assist consumers with applying for a QHP, including information about plan options.
Sets annual open enrollment periods for state marketplaces: CMS want to establish a consistent open enrollment period across all marketplaces. For state-run exchanges that don’t use the federal platform, this open enrollment period would begin November 1 and ends no earlier than January 15, the same period as the federal exchanges.
Maintains existing user fees: For the 2025 benefit year, CMS proposes the same user fee rates as 2024: a federally-facilitated marketplace user fee rate of 2.2 percent of total monthly premiums and state-based Marketplace-Federal Platform user fee rate of 1.8 percent of total monthly premiums.
Recalibrate HHS risk adjustment models: CMS wants to use the 2019, 2020, and 2021 enrollee-level EDGE data for recalibration of the HHS risk adjustment models. Using the three most recent consecutive years to recalibrate the model will provide stability and minimizes volatility in changes to risk scores between benefit years due to differences in the dataset’s underlying populations, while reflecting the most recent years’ claims experience available.
Reduces risk adjustment user fee: CMS proposes a risk adjustment user fee for the 2025 benefit year of $0.20 per member per month, a decrease from the 2024 benefit year risk adjustment user fee rate of $0.21 per member per month. For the 2025 benefit year, HHS will operate risk adjustment in every state and the District of Columbia. These costs cover development of the models and methodology, collections, payments, account management, data collection, data validation, program integrity and audit functions, operational and fraud analytics, interested parties training, operational support, and administrative and personnel costs dedicated to HHS-operated risk adjustment program activities.