CMS proposes PY 2025 rules for all Marketplaces

The Centers for Medicare and Medicaid Services (CMS) have laid out an ambitious blueprint for Marketplaces in Plan Year 2025, all to make Marketplaces more consumer-friendly. There's a ton here for consumers to love, meaning there's plenty for agents to be aware of.

Expanding Access to Health Care

Network adequacy standards: CMS is advocating for more robust network adequacy standards, urging states to enforce time and distance criteria that mirror those of the Federally Facilitated Marketplaces. Notably, telehealth services and provider availability will be key considerations. However, CMS has stopped short of proposing appointment wait time standards.

Essential Health Benefit (EHB) evolution: A groundbreaking suggestion involves potentially including routine adult dental services as an EHB. This move is a strategic effort to broaden access to dental care, particularly in communities facing marginalization.

Prescription drugs in the spotlight: CMS is poised to usher in a new era of consumer involvement in plan decisions. By mandating consumer presence on each plan's pharmacy and therapeutics committee, the aim is to inject objectivity into formulary choices. Additionally, the scope of drug coverage is set to expand, encompassing drugs not covered by a state's benchmark plan.

Flexible income and resource criteria: In a bid to make Medicaid expansion more adaptable, states might gain more control over income and resource considerations for non-MAGI populations. This proposal allows states to introduce additional income and resource disregards, providing flexibility, particularly in regions with high shelter costs.

Streamlining Plan Choices and Re-enrollment

Consistency in standardized plan requirements: While the agency aims to maintain current limits,  changes are anticipated in Maximum Out-of-Pocket Costs (MOOPS) and deductibles. CMS expresses a preference for pre-deductible coverage and copayments, emphasizing accessibility to care.

Non-standard plan exceptions: Recognizing the importance of addressing chronic or high-cost conditions, CMS is considering exceptions for carriers offering additional plans that reduce cost-sharing by 25%, relative to similar plans.

Empowering states in benchmark plan selection: A trilogy of changes unfolds, offering states more options in defining their EHB-benchmark plans. States can now select a set of benefits, deviating from the obligation to choose an existing plan. Second, the included benefits must now be at least as generous as a typical employer plan in the state. Finally, states are no longer required to submit updated formularies when changing their EHB-benchmark plans.

Transition from catastrophic plans: A significant proposal involves automatically enrolling individuals losing eligibility for catastrophic plans into a new Qualified Health Plan (QHP) during the Open Enrollment Period (OEP) for Plan Year 2025.

Easing Enrollment Barriers

Efficient Special Enrollment Periods (SEPs) and Basic Health Programs: To streamline processes, CMS proposes making coverage effective from the first of the month following plan selection for valid SEPs. This change excludes SEPs with retroactive effective dates. Moreover, those eligible for a state's Basic Health Program would enjoy a similar first-of-the-following-month effective date.

Annual reconciliation mandate: State marketplaces could see a new requirement—checking annually whether consumers have reconciled their Advanced Premium Tax Credits (APTCs). This mirrors the approach employed by the Federal Marketplace.

Simplified incarceration status verification: Recognizing the costs and potential issues with electronic verification, states may now opt for a simpler approach—relying on consumer attestation regarding their incarceration status to maintain enrollment eligibility.

Reinforcing Consumer Protections

Redefined state-mandated benefits:  Under this proposal, state-mandated benefits are no longer treated as an "addition to EHB." Instead, they are integral to EHBs, subject to nondiscrimination rules, cost-sharing limitations, and restrictions on annual or lifetime maximums.

State-Based Marketplace transition: To ensure a seamless transition and robust administration, CMS suggests a prerequisite for states to operate under a federal partnership for one year before transitioning to a state-based marketplace. This transition would be accompanied by the establishment of a centralized eligibility and enrollment platform, aligning with the streamlined application process on healthcare.gov.

Revitalizing Marketplace call centers: Marketplace call centers, including those operated by states, would witness a transformation. Live representatives would be mandatory, providing invaluable assistance to consumers navigating applications, subsidies, and enrollment. Furthermore, open enrollment periods, at a minimum, would mirror the Federal Marketplace Open Enrollment Period, spanning from November 1 through January 15.

That's not all

Some additional proposals wouldn’t have an immediately visible impact on consumers – things like requiring state Marketplaces to pay for access income verification data. There are some other changes to risk adjustment and user fees, too. Read about those changes, plus all the others.

Long story short, CMS is making many efforts to increase access to coverage, especially in marginalized communities. We’ll keep an eye on this rule, and let you know which proposals go into effect after the comment and rulemaking periods. If you’re looking to submit your comments, just stop by regulations.gov.