CMS finalizes marketplace network rules: 5 things to know

CMS finalized several proposed changes to regulations for the ACA marketplace in 2025. 

Advertisement

Beginning in 2026, the agency will require state-based marketplaces to adopt network adequacy standards that are at least as stringent as those required by the federal marketplace, according to an April 2 news release from CMS. These standards include the maximum time and distance beneficiaries can travel to the nearest in-network provider. 

CMS published its proposed rule in November. 

Here are five more changes to note: 

  1. CMS will allow states to include non-pediatric routine dental services as an essential health benefit. 
  2. The rules will standardize open enrollment periods across state and federal marketplaces. State-based marketplaces will be required to begin open enrollment on Nov. 1 and end open enrollment no earlier than Jan. 15. 
  3. CMS will extend special enrollment periods for those with incomes up to 150% of the federal poverty line. Low-income enrollees will be able to select marketplace coverage at any point during the year. 
  4. The new rule will add an exception to the limit of non-standard plans insurers can offer, designed to incentivize plans targeted toward specific chronic conditions. 
  5. Members enrolled in catastrophic plans will automatically be re-enrolled for the next year unless they opt for new coverage. The rule is designed to minimize coverage gaps, CMS said. 

Read more here. 

Advertisement

Next Up in Payer Policy Updates

Advertisement

Comments are closed.