CMS proposal would make several changes to ACA health plans

The comment period ended Monday for the Centers for Medicare & Medicaid Services’ Notice of Benefit and Payment Parameters proposed rule for 2025, which impacts the Affordable Care Act health insurance marketplaces.

The changes the proposed rule would make for 2025 include:

• An option for states to cover adult dental services as an essential health benefit. CMS proposes to remove the regulatory prohibition on insurers from including routine non-pediatric dental services as an essential health benefit. This would allow states to add routine adult dental services as an essential benefit by updating their EHB-benchmark plans.

CMS said including routine adult dental services as an essential benefit would remove regulatory and coverage barriers to expanding access to adult dental benefits. This proposal would also give states the opportunity to improve adult oral health and overall health outcomes, which could help reduce health disparities and advance health equity since these health outcomes are disproportionately low among marginalized communities. Under this proposal, states would be permitted to include routine non-pediatric dental services as essential benefits for purposes of their alternative benefit plans or basic health plans for low-income residents.

• Making it easier to enroll in coverage. CMS wants to align the effective dates of coverage after a consumer chooses a plan during a special enrollment period with the regular coverage effective dates across all marketplaces. CMS also proposes that consumers who enroll in coverage during a special enrollment period will receive coverage beginning the first day of the month after the consumer chooses a plan.

In addition, consumers with incomes at 150% of the federal poverty level would be permitted to enroll in coverage throughout the year instead of having to wait for a special enrollment period.

CMS proposes to provide states that operate the Basic Health Program additional flexibility in establishing an effective date of eligibility for enrollment in a standard health plan. The proposal would allow a state to select a standard in which applicants who meet all requirements are eligible to enroll in a standard health plan in the BHP effective the first day of the month following the month of application or eligibility determination regardless of when they apply or are found eligible to enroll.

The proposed CMS rules also would require all federal and state marketplaces to re-enroll consumers with catastrophic coverage, including enrollees who will lose their eligibility for catastrophic coverage, into a qualified health plan for the coming plan year.

• Improving access to prescription drugs. Under the current federal rules surrounding essential health benefits, health insurance plans must cover the greater of: one drug per class or category of the U.S. Pharmacopeia (U.S.P.) or the number of drugs covered by the state’s benchmark plan in each U.S.P. class and category. Federal regulations also require health insurance plans to establish Pharmacy & Therapeutics committees to evaluate new approved drugs or new indications in a timely manner.

In the CMS proposed rules for 2025, CMS proposes various amendments to these prescription drug standards. CMS wants to require health plans to include a consumer representative as part of P&T committees so that the consumer perspective would be considered when evaluating extending coverage to new drugs in the market without having to wait for updates to the U.S.P.

CMS also wants to codify a current policy that establishes that when health plans cover prescription drugs beyond the bare minimum, those additional drugs are still considered essential health benefits.