New Federal Updates to Affordable Care Act Marketplace Policy

The Centers for Medicare and Medicaid Services (CMS), the federal agency in charge of regulating most types of health insurance, just released a final rule that makes changes to the ACA Marketplace. The new final rule, called “Notice of Benefit and Payment Parameters for 2025,” includes many wins for Texas families who rely on care from the health plans governed by the Affordable Care Act (ACA). These changes will be in effect for the 2025 plan year, with some of the more complex changes phasing in through 2027. 

It is more important now than ever that Texans be able to find affordable, comprehensive coverage after the mass coverage losses from Medicaid unwinding. Last year, a record number of adults and children enrolled in Marketplace plans, and CMS has been working to strengthen both consumer protections and the coverage offered since. This rule is filled with policies that make it easier for people to find and receive the right health coverage and for states to set their own policies to facilitate that. 

Following are highlights of policies states can or must adopt over the next few years:

Dental care for adults can now be added as an Essential Health Benefit (EHB) by states. Each state can create what is called a “benchmark plan” with certain EHBs within parameters set by the ACA. This change will apply to most plans governed by the ACA, including those sold on ACA Marketplace Exchanges. Before this new rule, only pediatric dental care was allowed to be a part of EHBs; even if a state wanted to have a requirement to cover these vital services, it was unable to do so. We hope Texas takes advantage of this new allowance by adding adult dental care to its Benchmark Plan

The rule also makes a few updates to how prescription drugs are chosen and treated as EHBs. In order to ensure consumers’ voices are considered in the process, a representative from the patient community must now be on the state committee designing these benefits. The new rule also extends patient protections to prescription drugs health plans cover in addition to those listed as EHBs. This means if a plan covers prescription drugs that are not drugs the plan must cover, the ACA’s protections such as the bar on annual and lifetime limits also apply to those non-EHB drugs. 

CMS made some fairly technical changes to how health plans are designed and marketed so that consumers can have an easier time picking the right plan for themselves and their families. Consistent with changes made over the past couple of years, CMS made tweaks to its framework for standardizing plans; more standardization means fewer options and variables for consumers to consider, which in turn makes it easier for families to find the best-suited health coverage plan. There are also new lower-cost plans tailored to people with certain chronic or expensive-to-manage conditions a state can choose to offer.

Other parts of the rule are designed to make it easier to enroll in coverage. For example, new policy will make a “Special Enrollment Period (SEP)” available to certain consumers using Advanced Premium Tax Credits toward their premiums. These consumers are projected to make at or under 150% of the Federal Poverty Level in a year and to have a higher-than-zero percentage applied when their share of the premium is calculated. This SEP can be used at any time – not just when coverage is lost.  

Finally, the rule includes changes to how a state-based marketplace can be launched and operated. The ACA allows states to use the federally-facilitated marketplace – which is what Texas does – to either host a state-specific marketplace on the federal platform, or to have their own marketplace and system. The new rule requires states moving toward their own marketplace and system to have a full year of operation on the federal platform first; this will make sure the state is prepared and will avoid potential coverage losses. State-based marketplaces will also be required to host a “” enrollment system where eligibility can be checked across different coverage types and household members.  

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