In the recently released final HHS Notice of Benefit and Payment Parameters for 2025, the Centers for Medicare & Medicaid Services (CMS) finalized standards for issuers in the individual and small group markets and marketplaces as well as requirements for agents, brokers, web brokers, direct enrollment entities and assisters that help marketplace consumers. The final rule was accompanied by a Fact Sheet and Affordable Care Act FAQ Part 66 guidance. While most of the final rule is not relevant to employer-sponsored group health plans, it does change the definitions of certain essential health benefits (EHBs) that could potentially impact plan designs.
Specifically, the final rule includes the changes outlined below relevant to employer-sponsored group health plans.
CMS adopted a rule to remove the regulatory prohibition on issuers from including routine non-pediatric dental services as an EHB. This change would allow states to update their EHB-benchmark plans to add routine adult dental services as an EHB, removing regulatory and coverage barriers to expanding access to adult dental benefits.
If a self-insured plan adopts a state benchmark plan that covers non-pediatric dental as an EHB and that plan covers non-pediatric dental, then the plan could not impose annual or lifetime dollar limits on that coverage (unless the coverage meets the requirements to be an excepted benefit or limited scope dental).
CMS finalized revisions to certain EHB prescription drug benefit requirements by codifying its current policy that prescription drugs in excess of those covered by a state’s EHB-benchmark plan are considered EHBs in that they are subject to EHB protections. These protections include the annual limitation on cost sharing and the restriction on annual and lifetime dollar limits; however, if the coverage of the drug is mandated by state action and is in addition to EHBs, the drug would not be considered an EHB.
It was unclear if these provisions would apply to large and self-insured group health plans, and the final notice did not address this open issue. However, in FAQ Part 66, the departments of Labor, Health and Human Services, and the Treasury state that they intend to propose rulemaking that would align the standards that apply to large and self-insured group health plans with those that apply to individual and small group market plans; this would mean that all group health plans would be required to treat prescription drugs covered by the plan or coverage in excess of the applicable EHB-benchmark plan as EHBs for purposes of the prohibition of lifetime and annual dollar limits and the annual limitation on cost sharing applicable to non-grandfathered group health plans.
If all prescription drugs covered by a plan are eventually considered EHBs, then a large or self-insured group health plan could not impose annual or lifetime dollar limits on those drugs. This could be an issue for certain high-cost drugs, such as weight loss (obesity) and cancer drugs, and may impact whether or not a group health plan will continue to cover those drugs. Furthermore, if there would no longer be a way to define a covered drug as a “non-EHB,” then some copay accumulator or maximizer programs may no longer be available for employers to use.
With respect to the dental benefit provisions in the notice, states will be allowed to update their EHB-benchmark plans to include routine non-pediatric dental services via the EHB-benchmark application process beginning in 2025, which would first be effective for benefit years beginning on or after January 1, 2027.
With respect to the prescription drug provisions, timing is unknown and future guidance is expected.
