HHS seeks to streamline marketplace coverage, health benefits
The rule will standardize certain operations across the marketplaces with an eye toward increasing reliability and consistency, says HHS.
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New policies for Affordable Care Act Marketplaces, announced by the Department of Health and Human Services and the Centers for Medicare and Medicaid Services, are intended to make it easier for low-income people to enroll in coverage, the agencies said this week.
In addition, HHS said the policies provide states the ability to increase access to routine adult dental services and set network adequacy standards for the time and distance people travel for appointments with in-network providers.
Finally, the rule will standardize certain operations across the marketplaces with an eye toward increasing reliability and consistency.
WHAT'S THE IMPACT?
CMS has expanded access to dental benefits by finalizing measures to allow states the option to add routine adult dental services as an essential health benefit. For the first time, and starting on January 1, 2027, every state will be able to update their EHB-benchmark plans to include routine non-pediatric dental services, such as cleanings, diagnostic X-rays, and restorative services like fillings and root canals, through the EHB-benchmark application process beginning in 2025.
The rule seeks to create more consistent national standards on how far and how long a consumer must travel to see various types of providers in state marketplaces and state-based marketplaces on the federal platform (SBM-FPs). State marketplaces and state-based marketplaces must review a plan's network information prior to certifying any plan as a qualified health plan, consistent with the reviews conducted by the federally-facilitated marketplaces (FFMs).
In an attempt to make it easier to enroll in coverage, the rule extends the special enrollment period (SEP) for consumers with household incomes at or below 150% of the FPL for the 2025 plan year ($38,730 for a family of three) to enroll in coverage in any month rather than only during open enrollment. Previously, the SEP was only available when enhanced subsidies under the IRA were available.
The rule also aligns the dates of open enrollment periods across almost all marketplaces to generally begin on November 1 and end no earlier than January 15, with the option to extend the open enrollment period beyond January 15.
On top of that, the rule aims to prevent coverage gaps for those transitioning between different marketplaces or from other insurance coverage by allowing those selecting coverage during certain SEPs to receive coverage beginning the first day of the month after the QHP is selected, as opposed to coverage beginning at a later date if the consumer enrolls between the 15th and the end of the month.
THE LARGER TREND
The rule includes multiple policies to standardize operations among the federally-facilitated and state-based marketplaces to ensure a more streamlined consumer experience, such as requiring marketplaces to have live call center representatives available during call center hours of operation to assist consumers with QHP application submission and enrollment; generally holding open enrollment from November 1-January 15 (with the option for marketplaces to extend open enrollment to a later date); and automatically re-enrolling people who are enrolled in a catastrophic plan for the next year, in order to prevent gaps in coverage.
Jeff Lagasse is editor of Healthcare Finance News.
Email: jlagasse@himss.org
Healthcare Finance News is a HIMSS Media publication.
