On Nov. 15, CMS issued benefit and payment parameters for 2025.
HHS and CMS proposed 2025 notice of benefit and payment parameters for issuers.
Set payment parameters related to the HHS-operated risk adjustment program.
User fee rates for issuers offering Qualified health plans (QHPs) through Federally-facilitated exchanges (FFEs), State-based exchanges on federal platform (SBE-FPs).
Network Adequacy
State marketplaces and SBM-FPs must establish QHPs that are at least as stringent as Federally-facilitated marketplaces' (FFMs) time and distance standards set for QHPs.
Excluded Stand-alone dental plan (SADP) issuers in States that qualify for exception.
Issuers unable to meet specified standards would be able to submit justification.
Also proposed to collect information from QHP issuers about whether providers offer telehealth services to assist in informing network adequacy, provider access standards.
Removed prohibition on issuers from including routine non-pediatric dental services as an Essential health benefit (EHB), allowing States to add routine adult dental services.
Codified current policy that prescriptions in excess of those covered by a State’s EHB-benchmark plan are considered EHBs such that they are subject to EHB protections.
Provided States with greater flexibility to adopt income and/or resource disregards.
In determining financial eligibility for Medicaid for those individuals excepted from application of the Non-Modified adjusted gross income (MAGI) financial methodologies.
Plan Selection Process
Followed approach finalized in 2024 payment notice on standardized plan option metal levels and otherwise maintain continuity with approach to standardized plan options.
Modified the Max out-of-pocket (MOOP) and deductible values to ensure plans have Actuarial values (AVs) within the permissible de minimis range for each metal level.
Additionally, proposed an exceptions process to the limitation on the number of non-standardized plan options that issuers can offer in order to promote consumer access.
To plans with design features that facilitate treatment of chronic, high-cost conditions.
Consolidate options for States to change EHB-benchmark plans; State may change its EHB-benchmark plan by selecting a set of benefits that become EHB-benchmark plan.
Further, proposed to remove generosity standard and to revise the typicality standard.
Removed the requirement for States to submit drug list as part of documentation to change EHB-benchmark plans unless the State changes its prescription drug EHBs.
Amended the marketplace re-enrollment hierarchy to require all marketplaces to re-enroll enrollees with catastrophic coverage into a new QHP for the coming plan year.
Coverage Enrollment
Aligned effective dates of coverage after a consumer selects a plan during a special enrollment period subject to regular coverage effective dates across all marketplaces.
Including State marketplaces, beginning Jan. 1, 2025, or earlier date at market option.
Consumers who select and enroll in QHP during special enrollment period with regular coverage date receive coverage beginning the 1st day of the month after selection.
Set parameters around the availability of special enrollment period granted to advance payment of premium tax credit-eligible, qualified individuals at/below poverty level.
Defined processes for failure-to-reconcile status and incarceration status checks.
Marketplace Standards
Marketplaces must operate centralized eligibility and enrollment platform on website.
Set marketplace call center standards; must provide live help during operating hours.
Defined annual open enrollment dates for State not utilizing the federal platform.
Set standards to ensure web-brokers, direct enrollment entities meet HHS standards.
Healthcare.gov changes must be reflected on direct enrollment entity non-marketplace websites within period set by HHS; set Section 1332 waiver notice requirements.
Required State marketplaces, State Medicaid and Children’s Health Insurance Program (CHIP) agencies to pay to access income data via the verify current income hub.
Market Fees
Set FFM user fee rate of 2.2% of total monthly premiums and an SBM-FP user fee rate of 1.8%t of total monthly premiums, which are the same user fee rates as 2024.
Used 2019-2021 enrollee-level EDGE data for recalibration of risk adjustment models.
Recalibrated CSR adjustments factors for American Indian and Alaska Native (AI/AN) zero cost sharing and limited cost sharing plan variant enrollees for 2025 benefit year.
Also proposed to retain these proposed AI/AN CSR adjustment factors if finalized, for future benefit years unless changed through notice-and-comment rulemaking.
Risk adjustment user fee for the 2025 benefit year of $0.20 per member per month.
Which is a decrease from the 2024 benefit year risk adjustment user fee rate of $0.21.
Alongside this proposed rule, issued the 2025 benefit year premium adjustment percentage index and related payment parameters in guidance before Jan. 1, 2024.
Consultation
Comments due within 45 days of publication in the federal register, on Jan. 2, 2024.
Jan. 2024 NH INS Comments
On Jan. 11, 2024, NH INS expressed support for certain proposed changes to federal healthcare regulation; highlighted concerns and advocated for State flexibility.
Endorsed simplification of benchmark plan selection; expressed reservations re limited availability of non-standardized plans, particularly in markets with limited competition.
Recommend State-focus strategy in development of network adequacy requirements.
Apr. 2024 CMS Final Rule
On Apr. 2, 2024, CMS finalized standards for issuers and marketplaces, as well as requirements for agents, brokers, web-brokers, direct enrollment entities, assisters.
Final rule also includes several policies impacting Medicaid, Children’s Health Insurance Program (CHIP), and the Basic Health Program (BHP); also issued fact sheet on rule.
Build on Affordable care act (ACA) promise to expand access to quality, affordable care
