CMS tightening network adequacy standards for exchange plans

Beginning in 2025, health plans sold in state-run insurance exchanges would be required to meet time and distance standards that are at least as adequate as mandated on federal marketplaces, according to a rule released by the Centers for Medicare & Medicaid Services (CMS) on Wednesday.

Time and distance standards would be calculated at the county level and then applied to lists of provider specialties. The provision within the Notice of Benefit and Payment Parameters for 2025 rule does not apply to standalone dental plans in certain states and states can seek exemptions. No wait time standards will be imposed under the rule.

CMS proposed that state marketplaces collect information from health plan issuers about whether providers offer telehealth services to better inform network adequacy and provider access standards for future plan years.

It also would have state marketplaces mirror federal exchanges during the open enrollment period, meaning the sign-up period for both exchanges would take place from Nov. 1 to Jan. 15.

Wednesday’s rule allows states to add routine adult dental benefits as essential health benefits (EHB). The agency hopes this will expand access and remove barriers to receiving proper adult dental care. States would be granted the ability to include routine non-pediatric dental services as essential health benefits.

“This proposal would also give states the opportunity to improve adult oral health and overall health outcomes, which could help reduce health disparities and advance health equity since these health outcomes are disproportionately low among marginalized communities,” reads a press release from CMS.

The agency amended other EHB requirements in its rule, suggesting revising the minimum membership standards for pharmacy and therapeutics committees to include a consumer representative. It also wants to codify its current policy that prescription drugs not considered EHBs still enjoy protections, such as an annual limitation on cost sharing and dollar limits.

If finalized, changes will also be coming to the website. The website will now be required to display changes on direct enrollment on non-marketplace websites within a specific notice period for federal and state exchanges.

States would be required to use for at least one year after launching an exchange before moving on to their own platform.

“The changes that CMS proposes to require direct enrollment entities to make to their non-Marketplace websites include changes that would enhance the consumer experience, simplify the plan selection process, and increase consumer understanding of plan benefits, cost-sharing responsibilities, and eligibility for financial assistance,” said CMS.