CMS Issues Final Rule on HHS Notice of Benefit and Payment Parameters for 2025

Published April 03, 2024

The Department of Health and Human Services (HHS) though the Centers for Medicare & Medicaid Services (CMS) released a final rule for 2025 that sets standards for health insurers and the Affordable Care Act (ACA) marketplaces, as well as requirements for agents, brokers, and others who help consumers enroll in marketplace coverage.

In addition, HHS and CMS released ACA FAQ 66 that details the prohibition of lifetime and annual limits and annual limitations on cost sharing. The FAQ addresses the applicability of this provision in the final 2025 Notice of Benefit and Payment Parameters for self-insured group health plans and large group market plans.

Key provisions of the final rule include:

2025 payment parameters and provisions related to the HHS-operated risk adjustment program;
2025 user fee rates for issuers offering qualified health plans (QHPs) through Federally-facilitated Exchanges (FFEs) and State-based Exchanges on the Federal platform (SBE-FPs);
Requiring plans to include at least one patient representative to ensure that the consumer experience with a disease or condition is considered in the design of formulary benefits;
Requiring state-based marketplaces to operate a centralized eligibility and enrollment platform on the marketplace’s website to streamline enrollment applications for plans and insurance affordability programs;
Requiring that coverage begin the first day of the month after a consumer enrolls in marketplace coverage during a special enrollment period with a regular coverage effective date.

The rule also outlines requirements related to the auto re-enrollment process, covers requirements for prescription drug benefits, network adequacy, and public notice procedures for section 1332 waivers.

The final rule is effective June 4, 2024.

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