The Centers for Medicare and Medicaid Services (CMS) finalized its annual proposed guidance for Exchanges and Qualified Health Plans (QHPs) in two separate releases in April – the Notice for Benefit and Payment  Parameters for 2025 (NBPP) and the Letter to Issuers on the Federally-facilitated Exchanges for 2025 (Letter). As in prior years, the annual guidance addresses certification standards, financial parameters, and operational and technical guidance for Exchanges, QHPs, and premium stabilization programs. At the same time, CMS released its 2025 Actuarial Value Calculator and Methodology

PCG has updated our overview of the most significant changes that were initially outlined in the proposed NBPP and draft Letter to inform readers of which of those were finalized and of changes to what was proposed, with updates noted in bolded text.  Among the important policy changes for 2025 – and a topic top of mind for many regulators and QHP issuers – is the continued evolution of network adequacy standards. In addition to our topic-specific summaries, we have also flagged additional policy areas to which CMS has made changes that states may want to review as they prepare for the certification process.   
 

Network Adequacy  

The Letter finalized appointment wait time (AWT) standards for the Federally-facilitated Exchanges (FFEs) as previously proposed. The initial AWT standards, will go into effect for the 2025 Plan Year, requiring QHP issuers to attest that at least 90% of individuals are able to schedule an appointment within the time frames outlined in the Letter:  

• Behavioral Health: 10 business days  
• Primary Care (Routine): 15 business days   
• Specialty Care (Non-urgent): 30 business days  

CMS noted their particular interest in the ability of new patients to schedule initial appointments within these time frames.  

In acknowledgement of the comments it received regarding the importance of telehealth to ensure access to services, CMS has amended its approach to assess the 90% AWT standard compliance rate based on the shorter of in-person or telehealth services’ appointment wait-times.  

To validate compliance with the AWT requirements, the Letter also finalized the requirement that QHP issuers contract with third-parties to conduct secret shopper surveys. This will be a phased-in approach, with Plan Year 2025 secret shopper validation limited to primary care (routine visits) and behavioral health providers, and additional specialty categories added in subsequent plan years. The third parties conducting the secret shopper surveys must present as a new patient, and the secret shopper survey must be concluded by April 30th each year and reported to CMS. States should stay tuned for further secret shopper survey guidance that CMS has indicated it will publish later this year.  

In its continued efforts to address the holding in City of Columbus v. Cochran, CMS finalized its proposal in the NBPP to require State-based Exchange (SBE) and State-based Exchange on the Federal Platform (SBE-FP) states to establish and implement quantitative time and distance standards for QHP network adequacy that are at least as stringent as the FFE standards and to conduct quantitative network adequacy review consistent with FFE reviews. CMS updated the implementation timeline, with those requirements now not going into effect until 2026. SBE and SBE-FP states are not required to establish many of the other FFE standards initially, including related to appointment wait times, network transparency and inclusion of Essential Community Providers. Starting in 2026 SBEs and SBE-FPs will be required to require issuers to submit information on whether or not network providers offer telehealth services.
 

Essential Health Benefits 

CMS finalized significant policy shifts related to the Essential Health Benefits (EHBs) that will impact not only state’s EHB benchmarks, but also the liability of states for mandating coverage of services that are in addition to the EHB.  

Finalized changes include:   

• Eliminating the prohibition on insurers from including routine non-pediatric dental services in the EHB and allowing states to add those services to the state EHB benchmark. CMS will allow states to update the EHB benchmark to include routine non-pediatric dental via the application process beginning in 2025 for a 2027 effective date.   
• State mandated benefits that are part of the state’s EHB benchmark plan will no longer be subject to the defrayal requirements. 

Standardized Plans 

In the final Letter and NBPP CMS has finalized minor changes to standardized plan designs to ensure they stay within the actuarial value (AV) parameters for each metal level.  

Additionally, as finalized previously, starting in Plan Year 2025, the limit on non-standardized plan offerings will decrease from four per issuer product network type to two. The final Letter includes details and examples of how that limit will be applied. However, CMS also finalized its proposal to implement an exception process whereby issuers could seek approval to expand the number of non-standardized plans it offers in order to offer plans that facilitate treatment of chronic and high-cost conditions.  The final Letter also provides more details about the exception standards and process.
 

Other Changes of Note 

CMS finalized a number of changes related to SBEs, including related to standards for the eligibility and enrollment platforms, call centers and Open Enrollment Periods (OEPs). In the final regulations, CMS has added a grandfathering provision, allowing SBEs that held an OEP for 2024 that began before November 1st and ended before January 15th to continue with the same OEP in future years as long as it continues uninterrupted for a minimum of 11 weeks. CMS also finalized its proposal to require that states operate a SBE-FP for a year before they can transition to a full SBE.

CMS finalized the proposal to allow States seeking a Section 1332 Waiver and holding annual public forums on existing the waivers to hold virtual hearings.

CMS amended the 2025 user fees in finalizing them at a significant decrease for each based on increased enrollment in 2024: 

• 1.5% for FFEs  
• 1.2% for SBE-FPs

As states prepare for the upcoming certification process and the 2025 OEP, we also recommend reviewing proposed technical changes related to:  

• Prescription drug coverage and adverse tiering reviews 
• Reenrollment hierarchy   
• Special Enrollment Periods 
   

If your state has questions about any of the changes, please contact us at [email protected].