HHS finalizes policies to make marketplace coverage more accessible & expand essential health benefits

The Affordable Care Act includes a long list of codified instructions about what's required under the law. However, like any major piece of legislation, many of the specific details are left up to the agency responsible for implementing the law.

While the PPACA is itself a lengthy document, it would have to be several times longer yet in order to cover every conceivable detail involved in operating the ACA exchanges, Medicaid expansion and so forth. The major provisions of the ACA fall under the Department of Health & Human Services (HHS), and within that, the Centers for Medicare & Medicaid (CMS)

Every year, CMS issues a long, wonky document called the Notice of Benefit & Payment Parameters (NBPP) for the Affordable Care Act. This is basically a list of proposed tweaks to some of the specifics of how the ACA is actually implemented for the following year (actually, it's the year after the following year, since the final rule is generally released in mid-December).

The proposed version of the 2025 NBPP was released back in November; today, CMS issued the final version. I'll be doing a separate write-up on that as well, but here I'm focusing on the less wonky provisions which CMS is promoting in a separate press release:

Today, the Biden-Harris Administration, through the U.S. Department of Health and Human Services (HHS)’s Centers for Medicare & Medicaid Services (CMS), announced policies for the Affordable Care Act Marketplaces that make it easier for low-income people to enroll in coverage, provides states the ability to increase access to routine adult dental services, and sets network adequacy standards for the time and distance people travel for appointments with in-network providers.

Finally, the rule will standardize certain operations across the Marketplaces to increase reliability and consistency for consumers. The 2025 Notice of Benefit and Payment Parameters final rule builds on the Administration’s previous work expanding access to quality, affordable health care and raising standards for Marketplace plans nationwide.

“More than 21 million Americans signed up for high-quality, affordable health care coverage through the ACA Marketplaces in 2024. We want to build on this success to make Marketplace plans even better,” said HHS Secretary Xavier Becerra. “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 consumers with lower incomes can sign up for coverage when they need it.”

“Access to affordable, quality health care options remain a concern across the country and a top priority for CMS,” said CMS Administrator Chiquita Brooks-LaSure. “This rule includes groundbreaking ways to access health care services - such as addressing barriers for routine adult dental coverage for the first time and including considerations for how far people travel to see a health care provider. At CMS, we continue to explore ways to help Americans access high-quality coverage through the ACA Marketplaces.”

Increasing Access to Health Care Services

Adult Dental Services

CMS has expanded access to dental benefits by finalizing measures to allow states the option to add routine adult dental services as an essential health benefit (EHB). For the first time, and starting on January 1, 2027, every state will be able to update their EHB-benchmark plans to include routine non-pediatric dental services, such as cleanings, diagnostic X-rays, and restorative services like fillings and root canals, through the EHB-benchmark application process beginning in 2025.

It's important to stress that this doesn't mean every state will be required to include adult dental services as an EHB, just that they're allowed to do so (which apparently they weren't prior to this for some reason).

Network Adequacy

The final rule creates more consistent, nationwide standards on how far and how long a consumer must travel to see various types of providers in State Marketplaces and State-based Marketplaces on the Federal Platform (SBM-FPs). State Marketplaces and State-based Marketplaces must review a plan’s network information prior to certifying any plan as a qualified health plan (QHP), consistent with the reviews conducted by the Federally-facilitated Marketplaces (FFMs).

In short, this would require plans on all ACA exchanges (not just the states on the federal exchange) to meet certain thresholds like a primary care physician being available within a certain distance and/or a certain drive time from anyone enrolled in that plan, that an enrollee is able to make an appointment within a maximum number of days, and so forth. The rules would vary by county, which makes sense given that provider networks, population density and geographic distance varies widely from county to county. I assume this is supposed to be confirmed/enforced via "Secret Shopper" programs of some sort.

Making It Easier to Enroll in Coverage

Special Enrollment Periods

The rule extends the special enrollment period (SEP) for consumers with household incomes at or below 150% of the FPL (for the 2025 plan year, $38,730 for a family of three) to enroll in coverage in any month rather than only during Open Enrollment. Previously, this SEP was only available when enhanced subsidies under the IRA were available.

This one actually has me scratching my head. One of the main reasons for only allowing a limited time window for people to enroll is to prevent them from "gaming the system" (ie, waiting until they're sick/injured before they sign up for coverage). If you're eligible for a $0-premium policy anyway, however (as is the case for people earning less than 150% FPL under the enhanced subsidies provided by the IRA), there's no incentive to do this, which is why the sub-150% population is allowed to enroll year-round...as long as their net premium is nothing.

This change would allow them to still enroll year-round even if their net premium would be more than $0... which is what's going to happen to a significant chunk of enrollees assuming the IRA subsidies sunset at the end of 2025 as they're currently scheduled to do. If the IRA subsidies are extended or made permanent, of course (which I certainly hope happens), this is a moot point...but if they aren't, this partially defeats the entire point of having a limited-time Open Enrollment Period in the first place.

On the other hand, as others have noted, there should still be at least one Bronze plan available for $0 net premiums for enrollees who earn up to 150% FPL or higher in most counties anyway, so perhaps it wouldn't that big of a deal after all.

The rule also aligns the dates of Open Enrollment periods across almost all Marketplaces to generally begin on November 1 and end no earlier than January 15, with the option to extend the Open Enrollment period beyond January 15.

This one is targeting Idaho and New York: Idaho has been starting their annual Open Enrollment Period 2 weeks earlier (October 15th), which is fine...but they've also been ending it on December 15th, which isn't. Meanwhile, New York has been ending their OEP on January 31st (which is fine)...but they haven't been starting it until November 16th for some reason (which isn't).

Additionally, the rule aims to prevent coverage gaps for those transitioning between different Marketplaces or from other insurance coverage by allowing those selecting coverage during certain SEPs to receive coverage beginning the first day of the month after the QHP is selected, as opposed to coverage beginning at a later date if the consumer enrolls between the 15th and the end of the month.

Until now, in HealthCare.gov states, if you enroll during the off-season between, say, 3/01 - 3/15, your coverage would start on 4/01...but if you enroll between 3/16 - 3/31, your coverage wouldn't start until 5/01...up to six weeks later, which can be devastating for some people. This would bring HC.gov in line with some of the state-based exchanges, where you could enroll as late as 3/31 and still have your coverage start the very next day.

Streamlining the Enrollment Process

This rule includes multiple policies to standardize operations among the Federally-facilitated and State-based Marketplaces to ensure a more streamlined consumer experience, such as requiring Marketplaces to have live call center representatives available during call center hours of operation to assist consumers with QHP application submission and enrollment, generally holding Open Enrollment from November 1-January 15 (with the option for Marketplaces to extend Open Enrollment to a later date), and automatically re-enrolling people who are enrolled in a catastrophic plan for the next year, in order to prevent gaps in coverage.

All of which make sense to me.

Again, there's a bunch more NBPP provisions included in the fact sheet (along with more details about these ones), but I'll write those up separately.