CMS Releases Proposed Exchange Guidance for 2025
The Centers for Medicare and Medicaid Services (CMS) released its annual proposed guidance for Exchanges and Qualified Health Plans (QHPs) this month – the Proposed Notice for Benefit and Payment Parameters for 2025 (NBPP) and the Draft Letter to Issuers on the Federally-facilitated Exchanges for 2025 (Letter). As in prior years, the annual guidance addresses certification standards, financial parameters, and operational and technical guidance for Exchanges, QHPs, and premium stabilization programs.
With comments due on the Letter on January 2, 2024 and on the NBPP on January 8, 2024, PCG has provided a brief overview of the most significant changes outlined in the proposed NBPP and draft Letter to assist states as you consider whether to provide feedback. Among those – and a topic top of mind for many regulators and QHP issuers – is the continued evolution of network adequacy standards. In addition to our topic-specific summaries, we have also flagged additional policy areas to which CMS has proposed changes that states may want to review and provide comment to CMS on.
Network Adequacy
The Letter outlines important network adequacy changes for the Federally-facilitated Exchange (FFE) that are proposed to go into effect in 2025:
- The initial appointment wait time standards, which were previously postponed from implementation, are slated to go into effect for the 2025 Plan Year under the Letter, requiring QHP issuers to attest that at least 90% of individuals are able to schedule an appointment within the time frames outlined in the Letter:
- Behavioral Health: 10 business days
- Primary Care (Routine): 15 business days
- Specialty Care (Non-urgent): 30 business days
CMS noted their particular interest in the ability of new patients to schedule initial appointments within these time frames.
- To validate compliance with the appointment wait time requirements, the Letter proposes to require QHP issuers to contract with third-parties to conduct secret shopper surveys. This will be a phased-in approach, with Plan Year 2025 secret shopper validation limited to primary care (routine visits) and behavioral health providers, and additional specialty categories added in subsequent plan years. The secret shopper survey must be concluded by April 30th each year and reported to CMS.
In its continued efforts to address the holding in City of Columbus v Cochran, CMS is proposing in the NBPP to require State-based Exchange (SBE) and State-based Exchange on the Federal Platform (SBE-FP) states to establish and implement quantitative time and distance standards for QHP network adequacy that are at least as stringent as the FFE standards. Those states would not be required to establish many of the other FFE standards in 2025, including related to appointment wait times, network transparency and inclusion of Essential Community Providers.
Essential Health Benefits
CMS has also proposed significant policy shifts related to the Essential Health Benefits (EHBs) that will impact not only state’s EHB benchmarks, but also the liability of states for mandating coverage of services that are in addition to the EHB. Proposed changes include:
- Eliminating the prohibition on insurers from including routine non-pediatric dental services in the EHB and allowing states to add those services to the state EHB benchmark;
- Changes to the standards for state selection of benchmark plans starting for Plan Year 2027; and
- State mandated benefits that are part of the state’s EHB benchmark plan would no longer be subject to the defrayal requirements.
Standardized Plans
CMS has proposed minor changes to standardized plan designs to ensure they stay within the parameters for each metal level.
Additionally, as finalized previously, starting in Plan Year 2025, the limit on non-standardized plan offerings will decrease from four per issuer product network type to two. However, CMS is proposing to implement an exception process whereby issuers could seek approval to expand the number of non-standardized plans it offers in order to offer plans that facilitate treatment of chronic and high-cost conditions.
CMS is also seeking comment on requiring SBE issuers to offer standardized plans.
Other Changes of Note
CMS is proposing a number of changes related to SBEs, including related to standards for the eligibility and enrollment platforms, call centers and Open Enrollment Periods. CMS also proposes to require that states operate a SBE-FP for a year before they can transition to a full SBE.
States seeking a Section 1332 Waiver and holding annual public forums on existing the waivers would now be able hold virtual hearings under the proposed NBPP.
CMS is proposing to maintain the same user fees as 2024:
- 2.2% for FFEs
- 1.8% for SBE-FPs
As states consider commenting on the proposed Exchange guidance, we also recommend reviewing proposed technical changes related to:
- Prescription drug coverage
- Reenrollment hierarchy
- Special Enrollment Periods
If your state has questions about any of the proposed changes or would like assistance in compiling comments, please do contact us at healthpolicynews@pcgus.com.