Recently, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule to offer changes to the Patient Protection and Affordable Care Act (ACA) notice of benefit and payment parameters (NBPP) for the 2025 benefit year. The proposed rule seeks to update the ACA and health insurer standards, as well as risk adjustment payment methodologies. The annual NBPP rule governs policy changes for plans on the ACA Exchanges and sets rates and risk model specifications. Through the changes outlined in this rulemaking, CMS seeks to expand and establish new rates and model specifications while advancing health equity goals and mitigating health disparities.
More on Proposed Rule
In the proposed rule, the permanent risk adjustment program for fiscal year (FY) 2025 is subject to FY 2024 sequestration. Under this methodology, sequestered funds from FY 2025 at a rate of 5.7 percent will become available to pay issuers in FY 2025. CMS is proposing to determine the 2025 benefit year risk adjustment model using a blend of 2019, 2020, and 2021 External Data Gathering Environment (EDGE) data. The agency notes that while it adjusted for public health emergency (PHE) impacted anomalies in 2020 data for the 2024 proposed rule, it did not identify such anomalies in 2020 or 2021 data for 2025.
Furthermore, CMS is proposing updated standards regarding call center standards. Under the proposed rule, CMS would expand its current minimum standards for State Exchange call centers to require that consumers must have access to a live call center representative during all of the Exchanges’ hours of operation and that these representatives are able to assist consumers with their Qualified Health Plan (QHP) applications and enrollments. CMS is also proposing that representatives would also need to provide consumers with information regarding cost-sharing reduction eligibility and helping consumers understand QHP options available to them.
CMS is also seeking proposals on improvement of Special Enrollment Periods (SEP) and beginning dates of coverage. SEPs occur after Open Enrollment closes and follows a significant life event. Individuals have up to 60 days following a certain life event to enroll in a new plan. CMS is proposing the unification of enrollment effective dates across all Exchanges to allow enrollment periods to follow plan effective dates. This will allow for qualifying individuals or enrollees in a QHP to begin receiving coverage the first day of the month following plan selection.
Under the proposed rule, CMS would federally mandate that State Exchanges and State-based Exchange on the Federal Platform (SBE-FPs) establish and impose certain quantitative time and distance standards for their QHP networks. Specifically, for plan years beginning in 2025, State Exchanges and SBE-FPs would be required to impose time and distance standards that are as stringent as the standards for QHPs participating on the Federally Facilitated Exchanges (FFEs). These standards would also include requiring the minimum number of providers and specialty types for each network. Additionally, any plan seeking certification as a QHP would be required to undergo a network adequacy review and submit information on whether they would issue telehealth information. Under this proposal, CMS would institute a process for exceptions if the agency determines that the Exchange applies network adequacy standards that differ from the FEEs but still ensure reasonable access to quality care.
CMS is further proposing to retain the 2024 benefit year’s user fee rates for FFEs and SBP-FEs. Specifically, CMS is proposing a FFE user fee rate of 2.2 percent of total monthly premiums and an SBE-FP user fee rate of 1.8 percent of total monthly premiums. CMS states that a range of costs, premiums, and enrollment projections were used to develop the 2025 benefit year’s FFE and SBE-FP rates, noting that the finalized rates may differ if these estimates are significantly changed.