2025 Marketplace Final Rule Changes Agents Should Know

The Centers for Medicare & Medicaid Services (CMS) recently released the HHS Notice of Benefit and Payment Parameters for 2025 final rule, affecting the marketplace. We’ve summarized the major changes that agents should make note of before the 2025 Open Enrollment Period (OEP).

The Department of Health and Human Services (HHS) Notice of Benefit and Payment Parameters for 2025 final rule ensures that all carriers, marketplaces, agents, brokers, and others who carry out marketplace business are operating with the same standards. These changes will affect your Affordable Care Act (ACA) clients and business but are designed to improve access to health care services.

You can read the full 2025 marketplace final rule here. The following changes go into effect for plan year 2025, unless otherwise noted.

Changes That Will Affect ACA Agents and Clients

SBMs Required to Operate as SBM-FPs for One Year

CMS finalized that states must operate as a state-based marketplace (SBM) on the federal platform (SBM-FP) for at least one year before fully transitioning to an independent state marketplace. State marketplaces will evaluate eligibility and enrollment on their websites. This will allow state marketplaces to determine eligibility and allow individuals to enroll in coverage on the same platform. The transition simplifies the enrollment process for clients and the agents supporting them.

Entities in SBMs Must Meet HHS Standards

Any web-broker or direct enrollment entity operating in any state marketplace must meet the established HHS standard already in place for entities operating on the Federally Facilitated Marketplace (FFM) and SBM-FPs. Standards pertain to providing consumers with correct information, disclaimer language, application assisters, access by downstream agents and brokers, and operational readiness.

Synchronized Open Enrollment Dates

Going forward, state marketplaces must utilize, at a minimum, the same OEP dates as the federal marketplace. This is a great improvement for agents operating in more than one exchange — one major date range to remember when your clients need to be enrolled in health coverage!

This standard OEP would begin on November 1 and end no earlier than January 15. The only exception to this rule is that states with an already established OEP may keep it for future years as long as it lasts 11 weeks and no changes are made to its dates.

This standard OEP would begin on November 1 and end no earlier than January 15.

Non-Pediatric Dental Benefits to Become Essential Benefits in 2027

States can update their essential health benefit (EHB) benchmark plans to include routine dental care benefits for adults. Previously, dental coverage was only available for pediatric clients with a marketplace plan.

Marketplace adult dental benefits will be available on or after January 1, 2027 — after states review their EHBs in 2025. Coverage can include cleanings, X-rays, fillings, and root canals. CMS cites that adding dental coverage as a benefit allows states to improve the overall health of individuals and limit health disparities.

CMS cites that adding dental coverage as a benefit allows states to improve the overall health of individuals and health equity.

New Re-Enrollment Requirements for Clients with Catastrophic Coverage

All marketplaces will now re-enroll any enrollee who has a catastrophic coverage plan into a qualified health plan (QHP) for the next plan year. This rule includes those who are losing eligibility for catastrophic coverage.

If the enrollee’s current plan is no longer available or they’re losing eligibility for catastrophic coverage, the marketplace will re-enroll them into a plan that’s the same product as their current QHP or a plan that is the most similar and has the same network. This may mean that they’ll be enrolled in a plan with the lowest coverage level under their current carrier.

FPL SEP Extension

Consumers with income levels at or below 150 percent of the federal poverty level (FPL) will continue to have access to a Special Enrollment Period (SEP) to update their coverage. (For example, the extended FPL SEP would apply for a family of three with an income of $38,730.) Previously, this SEP was only approved through 2025, along with the enhanced subsidies under the Inflation Reduction Act. It is now an ongoing optional SEP for all marketplaces.

Reduced Coverage Gaps After SEP Selection

Ensuring access to affordable health care is the number one priority of the marketplace, and this year’s final ruling continues to make improvements. For individuals who select coverage during an SEP, their new marketplace plan will be active on the first of the month following the month they enroll in their new plan.

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This year’s HHS 2024 Notice of Benefit and Payment Parameters Final Rule aims to improve marketplace coverage, provide quality health care options, and simplify plan choices. We encourage ACA agents to take note of the changes for the upcoming enrollment period and share the information with clients. If you have questions about selling marketplace insurance plans, contact your sales specialist.

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