April 10, 2024

HHS Announces 2025 Final Rule: Enhanced Access and Standards for Healthcare Marketplaces

By Erin Lanzarone, Supervisor, Assurance Services

Healthcare

On April 2, 2024, the U.S. Department of Health and Human Services (HHS) released the Notice of Benefit and Payment Parameters (Payment Notice) for the 2025 final rule. Consequently, the Centers for Medicare & Medicaid Services (CMS) finalized standards for issuers, as well as requirements for agents, brokers, and assistants who help Marketplace consumers. In addition to the above, this final rule included policies impacting the Medicaid Program. These new policies build on the Affordable Care Act’s mission to expand access to quality and affordable health coverage by increasing access to healthcare services, simplifying the choice and plan selection process, making it easier to enroll in coverage, and enhancing standards and guaranteed consumer protections, reinterpreting the authority to access specific data through Medicaid, CHIP, and Marketplace Hub Services. Here, we will focus on the changes made from the 2024 Final Rule, specifically relating to increasing access to healthcare services in the Marketplace and ensuring those plans are adequate.

Increasing Access to Healthcare Services

The 2025 Final Rule stressed the importance of ensuring the Marketplace provided reasonable, timely access to health care providers. CMS finalized that State Marketplaces, or State-based Marketplaces, on the Federal platform (SBM-FPs), must create and enforce quantitative time and distance qualified health plans (QHP) network standards that are, at a minimum, as stringent as the Federally-facilitated Marketplaces’ (FFM). This is an effort on CMS’ part to ensure that the adequacy standards used at the federal level are followed at the state marketplace level and are mandated for plan years beginning on or after January 1, 2026. This standard further propels the Affordable Care Act’s momentum to increase access to healthcare services and ensure that the plans available in the Marketplace are in the best interest of the qualified individuals in that state.

Furthermore, the 2025 Final Rule advances the Affordable Care Act’s promise to ensure the plans’ quality is appropriate and acceptable. CMS finalized the standard that State Marketplaces and SBM-FPs must conduct network adequacy reviews to evaluate a plan’s compliance with the network adequacy standards, and this must be done before certifying that a plan is a qualified health plan (QHP). Issuers of the plan can provide justifications to their State Marketplace for any reason that they may not meet such standards, which the State Marketplace can then review. However, the State Marketplace will review the justifications provided by the plan through the lens of qualified individuals rather than the issuer. Essentially, the State Marketplace will evaluate the rationale to determine if making the plan available through the Marketplace is in the best interest of the qualified individual. Considerations made by the State Marketplace can include – local availability of providers and other variables reflected in the local patterns of care for that Marketplace.

Lastly, effective for plans beginning January 1, 2026, CMS finalized the standard that State Marketplaces and SBM-FPs issuers seeking QHP certification must submit information to the State Marketplace or SBM-FP about whether network providers offer their qualified individuals telehealth services.

These standards further propel the momentum of the Affordable Care Act’s mission to increase access to healthcare services and ensure that the plans available in the Marketplace are in the best interest of the qualified individuals in that state and meet a level of adequacy that benefits the qualified individuals.

Understanding the implications of the new 2025 Final Rule is imperative to healthcare entities as they help their patients navigate the choices and options available in the ever-evolving Marketplace. For further information on this release, including provisions not discussed herein, see the CMS website. Please reach out to the Marcum healthcare team today if you have any questions.