CMS final rule improves access to Affordable Care Act marketplace coverage
The rule expanded the special enrollment period to allow consumers with household incomes at or below 150 percent of the federal poverty level to apply for marketplace coverage outside open enrollment.
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- CMS has finalized policies to increase access to marketplace coverage and expand essential health benefits (EHBs) in the HHS 2025 Notice of Benefit and Payment Parameters final rule.
“Access to affordable, quality health care options remain a concern across the country and a top priority for CMS,” CMS Administrator Chiquita Brooks-LaSure said in the press release. “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.”
The rule includes requirements for State Marketplaces and State-based Marketplaces on the Federal platform (SBM-FPs) to establish and enforce quantitative time and distance qualified health plan (QHP) network adequacy standards that are at least as strict as the Federally-facilitated marketplaces’ standards. In addition, State Marketplaces and State-based Marketplaces must review a plan’s network information before certifying it as a QHP.
CMS also expanded access to dental benefits and will allow states to add routine adult dental services as an EHB starting on January 1, 2027. States will be able to update their EHB-benchmark plans to include routine services such as cleanings and diagnostic X-rays and restorative services like fillings and root canals through the application processing starting in 2025.
The rule codified a current CMS policy stating that prescription drugs that a plan covers in excess of those covered by a state’s EHB-benchmark plan are considered EHBs unless a state action mandates coverage.
Several policies in the rule aim to facilitate enrollment in marketplace plans. For example, CMS extended the special enrollment period for consumers with household incomes at or below 150 percent of the federal poverty level. This will allow these consumers to enroll in coverage in any month rather than only during the open enrollment period. Initially, the special enrollment period was only available when enhanced subsidies under the Inflation Reduction Act were available.
The rule aligns the dates of open enrollment periods across most marketplaces to begin on November 1 and end no earlier than January 15, with the option to extend the period beyond that end date. The rule also allows consumers selecting coverage during certain special enrollment periods to receive coverage starting the first day of the month after the QHP is chosen rather than a later date if they enroll between the 15th and the end of the month.
Additionally, the rule finalized policies to standardize operations among the Federally-facilitated and State-based Marketplaces to create a more streamlined consumer experience. CMS will require marketplaces to have live call center representatives available to help consumers with QHP application submission and enrollment. Marketplaces will also have to automatically re-enroll people enrolled in a catastrophic plan for the next year to prevent coverage gaps.
The 2025 final rule includes other policies related to user fees, consumer protections, and web brokers operating in marketplaces. The complete rule can be found here.
