HHS Finalizes Policies to Make Marketplace Coverage More Accessible and Expand Essential Health Benefits

Today, the Biden-Harris Administration, through the Centers for Medicare & Medicaid Services (CMS) of the U.S. Department of Health and Human Services (HHS), announced Affordable Care Act marketplace policies to make health care more accessible to low-income people. coverage, allowing states to increase access to routine adult dental services and set network adequacy standards for when and how far people can schedule appointments with in-network providers. Finally, the rules will standardize certain operations across the market to increase reliability and consistency for consumers. The 2025 Notice of Benefits and Payment Parameters final rule builds on the Administration's previous work to expand access to quality, affordable health care and raise standards for marketplace plans nationwide.

“By 2024, more than 21 million Americans will have signed up for high-quality, affordable health insurance through the ACA Marketplaces. We hope to build on this success and make the Marketplace program even better,” said HHS Secretary Ze Xavier Becerra said. “This rule will allow coverage of routine dental benefits for the first time, expand requirements to ensure reliable access to health care providers, and ensure that lower-income consumers can sign up for coverage when they need it.”

“Access to affordable, quality health care options continues to be an issue nationwide and a top priority for CMS,” said CMS Administrator Chiquita Brooks-LaSure. “This rule includes groundbreaking ways to access health care, such as addressing barriers to regular adult dental coverage for the first time and considering how far people have to travel to see a health care provider. At CMS, we continue to explore ways to help Americans through the ACA Marketplaces are your way to get high-quality insurance.

Increase access to health care services
Adult dental services

CMS is expanding access to dental benefits by finalizing measures that give states the option to add routine adult dental services as an Essential Health Benefit (EHB). Starting January 1, 2027, for the first time, each state will be able to update its EHB baseline plan to include routine non-pediatric dental services such as cleanings, diagnostic X-rays, and restorative services such as fillings and root canals, through the EHB baseline starting in 2025 application process.

network adequacy

The final rule establishes more consistent national standards for how far and how long consumers must travel to see various types of providers in the State Marketplace and in the State Marketplace on the Federal Platform (SBM-FP). State marketplaces and state marketplaces must review a plan's network information before certifying any plan as a qualified health plan (QHP), consistent with the review conducted by the Federally Facilitated Marketplace (FFM).

Make insurance easier
Special enrollment period

The rule extends the Special Enrollment Period (SEP) for consumers with household incomes at or below 150% of the FPL ($38,730 for a family of three in the 2025 plan year) to enroll in any month, not just when enrollment is open Insure during the period. Previously, this SEP was only available when providing enhanced benefits under an IRA.

The rules also adjust the open enrollment period dates for nearly all markets, which generally begin on November 1 and end no earlier than January 15, with the option to extend the open enrollment period beyond January 15.

Additionally, the rule is intended to be effective by allowing those who elect coverage during certain SEP periods to obtain coverage beginning on the first day of the month following the month after electing a QHP, rather than starting on the first day of the month following the month after electing QHP if the consumer signed up between the 15th and the end of the month. It will be a later date.

Simplify the registration process The rule includes multiple policies to standardize operations between federally driven markets and state markets to ensure a more streamlined consumer experience, such as requiring markets to have live call center representatives available during call center operating hours to assist with consumer submissions. QHP applications and enrollment, generally open enrollment between November 1 and January 15 (markets have the option to extend open enrollment to a later date), and automatically re-enrolls people in the next year's catastrophic plan to prevent Coverage gaps.

For more information about the final rule, please see the fact sheet: https://www.cms.gov/newsroom/fact-sheets/hhs-notice-benefit-and-payment-parameters-2025-final-rule

Click here to view the final rule: https://www.cms.gov/files/document/cms-9895-f-patent-protection-final.pdf

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