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CMS Finalizes 2025 Benefit and Payment Parameters Rule

The Centers for Medicare & Medicaid Services (CMS) on April 2 published its annual updates to benefit and payment parameters for federal health care marketplaces, state-based marketplaces on the federal platform (SBM-FPs), and, now, state-based marketplaces.

State Marketplaces

CMS finalized several changes to state marketplace requirements to better align them with federal marketplace requirements:

  • For plan years beginning on or after Jan 1, 2026, state marketplaces and SBM-FPs must establish and impose quantitative time and distance adequacy standards for qualified health plan networks that are at least as stringent as those on the federal marketplace.
  • Open enrollment dates are standardized for all marketplaces from Nov. 1 to Jan. 15. CMS exempted open enrollment periods on state marketplaces that begin before Nov. 1 and end before Jan. 15, as long as the period is at least 11 continuous weeks.
  • Improvements for state selection of essential health benefit (EHB)–benchmark plans.

Medicaid Provisions

The rule also contains two Medicaid provisions:

  • Beginning July 1, state Medicaid agencies and marketplaces must pay to access income data via the Verify Current Income Hub Service.
  • State-mandated benefits will not be considered “in addition to EHB” if the mandated benefit is an EHB in the state’s EHB-benchmark plan. This might affect state basic health plans and Medicaid alternative benefit plans.

CMS is not finalizing a proposal to give states greater flexibility to adopt income or resource disregards in determining financial eligibility for non–modified adjusted gross income populations (blind or disabled people who qualify for Medicaid regardless of income). The agency says this proposal could allow states to narrow existing disregards. CMS will continue to evaluate the issue.

CMS will maintain its approach to streamlining the plan selection process with standardized plans. The agency finalized an exception for the number of nonstandardized plan options that reduce cost and increase benefits for chronic conditions. CMS made no changes to essential community provider requirements.

America’s Essential Hospitals is analyzing the rule and will send members a detailed Action Update in the coming days.

Contact Senior Vice President of Policy and Advocacy Beth Feldpush, DrPH, at bfeldpush@essentialhospitals.org or 202.585.0111 with questions.

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About the Author

Julie Kozminski is a policy manager at America's Essential Hospitals.

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