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The Department of Health and Human Services (HHS) issued its 2025 Notice of Benefit and Payment Parameters (NBPP) earlier this week, which finalizes changes to Exchange plans established by the Affordable Care Act (ACA).
An item of note for the rheumatology community is the issue around copay maximizers and alternative funding programs, which HHS addresses by codifying in regulation that prescription drugs in excess of those covered by a State’s EHB-benchmark plan are considered EHB, thus subject to both the annual limitation on cost sharing and the restriction on annual and lifetime dollar limits.
As the finalized policies apply to issuers of non-grandfathered individual and small group market plans subject to the requirement to provide EHB, not self-insured group health plans and large group market health plans, HHS is working with the Departments Labor and Treasury on rulemaking that would align the standards applicable to large group market health plans and self-insured group health plans with those applicable to individual and small group market plans. HHS also said it will consider copay maximizer programs in any subsequent policy making about drug manufacturer assistance programs.
In addition to CSRO’s comments, we joined the Alliance of Specialty Medicine in providing additional comments recommending the Department include additional provider and facility specialty types to the time and distance standards that Exchanges must meet. Network adequacy is a growing issue for rheumatology, particularly in Medicare Advantage (MA) and in certain states. CSRO, along with the Alliance, will continue to press for improvements in network adequacy standards across MA and the Exchanges. HHS did acknowledge those comments, but was not inclined to make any updates at this time.
For more information about the final rule, view the CMS fact sheet. Additional details about the appointment wait time standards will be released in the coming months and CSRO will continue to provide updates as appropriate.
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