The U.S. Department of Health and Human Services (HHS) and its Centers for Medicare & Medicaid Services (CMS), announced significant policy changes aimed at enhancing the Affordable Care Act (ACA) Marketplaces. These new policies are designed to make it easier for low-income individuals to enroll in coverage, expand access to routine adult dental services, and establish clear standards for the accessibility of in-network healthcare providers. The finalized 2025 Notice of Benefit and Payment Parameters rule aims to build on the administration’s ongoing efforts to improve access to quality, affordable healthcare nationwide.
HHS Secretary Xavier Becerra highlighted the impact of these changes: “More than 21 million Americans secured high-quality, affordable healthcare coverage through the ACA Marketplaces in 2024. We are committed to building on this success to further enhance Marketplace plans. This new rule allows for the inclusion of routine dental benefits, sets stringent access requirements for healthcare providers, and ensures that low-income consumers can enroll in coverage whenever they need it.”
CMS Administrator Chiquita Brooks-LaSure emphasized the broader goals of these reforms: “Ensuring access to affordable, quality healthcare remains a top priority for CMS. This rule introduces innovative measures to overcome barriers to care, including the addition of routine adult dental coverage and considerations for travel distances to healthcare providers. CMS continues to explore ways to facilitate access to high-quality coverage through the ACA Marketplaces.”
Expanding Access to Health Services: Key Provisions
Adult Dental Services Starting January 1, 2027, states will have the option to include routine adult dental services as essential health benefits (EHBs). This expansion will allow states to update their EHB-benchmark plans to cover services such as cleanings, diagnostic X-rays, and restorative treatments like fillings and root canals. This change, set in motion through the EHB-benchmark application process beginning in 2025, marks a significant advancement in dental care access for adults.
Network Adequacy The new rule establishes consistent national standards for the distance and time consumers must travel to access various types of healthcare providers. State Marketplaces and State-based Marketplaces on the Federal Platform (SBM-FPs) will now need to review and certify a plan’s network information before approving any plan as a qualified health plan (QHP), aligning with the practices of Federally-facilitated Marketplaces (FFMs).
Facilitating Easier Enrollment: Special Enrollment Periods
Special Enrollment Periods (SEPs) The rule extends SEPs to allow individuals with household incomes at or below 150% of the Federal Poverty Level (FPL) to enroll in coverage at any time during the year, rather than only during the Open Enrollment period. This expansion aims to provide continuous access to healthcare for low-income households, ensuring they can obtain coverage when they need it most.
Aligned Open Enrollment Periods Open Enrollment periods across most Marketplaces will now generally run from November 1 to January 15, with an option for extensions. This alignment is designed to provide a more predictable and streamlined enrollment process for consumers.
Preventing Coverage Gaps The rule includes measures to prevent coverage gaps for individuals transitioning between different Marketplaces or from other insurance coverage. This provision ensures that those selecting coverage during certain SEPs will have their new coverage begin on the first day of the following month, reducing the risk of uninsured periods.
Streamlining Operations for a Better Consumer Experience
To enhance the consumer experience, the rule standardizes operations among Federally-facilitated and State-based Marketplaces. Key policies include ensuring live call center representatives are available during operating hours to assist with QHP applications and enrollment, standardizing the Open Enrollment period, and implementing automatic re-enrollment for individuals in catastrophic plans to prevent coverage lapses.
These comprehensive changes by the Biden-Harris Administration underscore a commitment to making healthcare more accessible, reliable, and affordable for all Americans. By addressing critical gaps and ensuring continuity of care, these new policies represent a significant step forward in the nation’s healthcare landscape.
~ S. Green
For more information on the final rule, see the fact sheet at 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-patient-protection-final.pdf
