In today’s episode of Regulatory Joe, we’re taking a deep dive into what’s changing for 2025 with one of the most critical federal policy guidelines impacting health plans: the Notice of Benefit and Payment Parameters (NBPP).
The NBPP is an annual set of federal guidelines released by the Centers for Medicare & Medicaid Services (CMS) that governs how health plans operate, with a specific focus on plans on the Affordable Care Act (ACA) marketplace. The NBPP outlines key rules and provisions for health insurers to follow, including essential health benefits (EHBs), payment parameters, operational requirements and enrollment rules.
Key Changes in the 2025 NBPP
The final 2025 NBPP was released earlier this year and highlights several key changes that will impact how plans design and price their offerings.
- Expanded access to telehealth services
While telehealth services have been a part of CMS’ rules and regulations for years, the 2025 update specifies that plans will be required to document telehealth status for providers more rigorously. This includes identifying telehealth status of providers across plan templates, such as those used for Essential Community Providers (ECP) and network adequacy filings. - Prescription drug access
A new rule from the 2025 NBPP mandates that health plans include not just generic drugs, but also preferred brands and specialty medications in their formularies. These medications also need to be set at more affordable rates through cost-sharing provisions, making them more accessible for individuals managing long-term, chronic conditions like diabetes, cancer or autoimmune diseases. - Re-enrollment hierarchy
The 2025 NBPP introduced new rules around the re-enrollment hierarchy, which will streamline the process for members losing subsidies. Most members who don’t actively select a plan will be automatically renewed into their current plan, if it’s still available, ensuring that members don’t lose coverage because they didn’t re-enroll. For members receiving subsidies, or financial assistance to help pay for premiums, the process is streamlined to automatically move them into plans that align with their financial circumstances. - Standard plan options
CMS is encouraging carriers to reassess their current filing processes for standard plan options, particularly in preparation for healthcare.gov and state-based exchange displays. This will ensure more consistent benefit designs across exchanges. - Strengthening market regulations
CMS is doubling down on network adequacy and transparency in coverage for 2025, requiring health plans to bolster their provider networks and adhere to stricter time and distance standards for network adequacy. In addition, new transparency requirements will require plans to furnish detailed claim data, making healthcare information more easily accessible and understandable.
Regulatory Joe Recommendations
- Start preparing for telehealth integration ASAP.
Operationally, documenting telehealth services can be a daunting task—especially for smaller carriers. By implementing technical systems early on, plans will prevent future inefficiencies when the new telehealth rules come into full effect. This could involve updating internal systems or partnering with external vendors to manage and report this data accurately. - Prepare for re-enrollment hierarchy changes.
Carriers need to review their internal processes to handle the new re-enrollment hierarchy for 2025, particularly for members who are losing subsidies. This includes understanding how subsidy changes affect members and ensuring that systems are in place to automatically enroll members into new plans when necessary. Plans should also be analyzing why members might leave their current plans and take steps to retain members. - Reassess standard plan filing processes.
All health plans need to reassess their standard plan filing processes to comply with new requirements, especially carriers submitting plans to healthcare.gov and state-based exchanges. In addition, plans should start developing long-term strategies for 2026 and beyond, ensuring that procedures can adapt to further standardization in the future. - Appoint a designated point of contact for CMS and state communication.
It’s crucial to name a designated point of contact to work directly with CMS or state divisions of insurance. These contacts are often part of your government affairs, legal or product team and will be responsible for receiving and implementing federal rules and guidelines within your organization. This point of contact will be crucial in collecting feedback on future NBPP drafts and submitting comments during the allotted time period CMS provides. - Stay informed through webinars and newsletters.
To stay ahead of regulatory changes, be sure to register for and attend the weekly REGTAP webinars where CMS provides updates and subscribe to CMS’s Public Federal Newsletter to receive real-time alerts on key regulatory changes.
From expanding telehealth access and prescription drug coverage to strengthening network adequacy standards, the 2025 NBPP updates require both strategic and operational adjustments from health plans. By staying ahead of these changes, carriers can ensure compliance and better care for their members—a win-win.
Be sure to watch the full episode for a more detailed run-down of changes and recommendations.
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Video Transcript
Welcome to Regulatory Joe.
I’m Joe Boyle, the president of regulatory solutions here at Penstock.
And in today’s episode, we’ll be talking about the Notice of Benefit and Payment Parameters for plan year 2025.
What is the NBPP?
This could be arguably the most important piece of federal policy guidelines put forth and released by CMS on an annual basis.
Generally speaking, CMS will release a draft version of the NBPP in Q4 of each calendar year.
Generally speaking, around November or December time frame, allowing issuers to form a position and produce comments to lobby in favor or against some of the federal rules that are proposed to be released.
Understanding that policy guidelines from CMS could mean something vastly different for larger carriers, as it does to a smaller carrier, it’s important for each organization to fully understand each of the provisions and key provisions that are released by CMS before you make operational decisions.
Let’s go ahead and take a look and dive into some of these provisions to better understand them for plan year 2025.
Starting with one of the more important key provisions, which would be expanding access to telehealth services, it’s very clear that CMS has had a focus on this provision for the past number of years, now enforcing it for plan year 2025.
We have seen aspects of telehealth in the day-to-day filing operations, whether it’s designating your telehealth status for a provider on your ECP or network adequacy template, or in your supplemental state-specific supporting documents that you file within your binders or your forms.
But CMS is now taking that to the next level.
The implications of this are going to be much easier for larger carriers to accommodate telehealth services and integrations with those providers than smaller carriers.
Having to actually strike up and produce those contracts with those PCPs or specialists is no small task.
And as CMS does enforce this, when you’re filling out your ECP and network adequacy templates or even your MPMS applications, it’s going to be a big challenge, operationally speaking, to input not just five, ten, 15, but we’re talking hundreds of thousands of lines of data identifying if a provider offers telehealth or not.
We did see this as a large issue this past plan year when we filed and submitted with CMS.
So we encourage you all to start to develop business processes, implement technical intervention to the systems that house your provider data, whether it’s a system like Onyx or if you partner with an external system like Quest.
Please get ahead of this or else you will encounter operational inefficiencies sometime around next April or May.
Another key provision CMS focused on for 2025 was Essential Health Benefits, or EHBs.
We did see a heavy focus this year on access to prescription drugs, not just limited to generics, but also preferred brand and also specialty drugs.
We do feel this rule is overall positive from CMS, increasing access to drugs and making them more affordable for members to treat the conditions that they have today.
When we talk about enrollment, one of the other key provisions that CMS was focusing on for 2025 was the re-enrollment hierarchy.
We’ll likely see more activity around the re-enrollment hierarchy closer to November 1st.
But it’s important to know that there are two types of enrollment: passive enrollment and active enrollment.
And what we’ll see this year in the re-enrollment hierarchy as members complete their applications for 1/1 effective coverage is that their subsidies will, in fact, change.
For members who are losing subsidies, CMS is looking to streamline the re-enrollment process for these members, specifically as they look to be enrolled into brand new plans.
It’s important to know this because not all members will be enrolled into new plans, as most members will be auto-renewed or re-enrolled into the same plan for next year.
The re-enrollment hierarchy always causes operational nuances inside of a health plan because as members change plans, they also change their HIOS IDs.
That has implications to how we crosswalk our plans for the prior plan year and the future plan year, and how they’re administered within any organizational database.
As plans change, this will also have an impact to when accumulators reset on a plan.
When those deductibles and out-of-pocket maximums go back to zero, members will start accruing against their deductible starting January 1st.
It’s also important to recognize that the re-enrollment hierarchy is not just in the for benefit of the member to streamline that process, but carriers should be taking a hard look at their internal operational processes to understand where their members are going.
Based on the re-enrollment hierarchy and if subsidy levels do change, will members be leaving their current carrier or current organization to seek a new brand?
If so, why?
How can you retain your members inside of your current plan?
You should definitely be taking some time with your operational teams to develop a plan strategy to look at your current membership, your future projections, and also your current enrollment process internal to your company.
We all know the march up to 11/1 is a busy, busy time.
And it’s important to know that if you haven’t looked at your call center staffing or your call center standards, now’s the time.
I think the overall theme that we can look forward to with CMS enforcing call center standards for 2025 is carriers can expect reduced member escalations, they can expect reduced repeat calls and also reduced call times with members all in the benefit to keep call times short and return calls limited.
One of the more complex items that carriers had to stumble through earlier this year were standard plan options, as well.
What we’re going to see is now that carriers have actually mapped their plans, reduced their standard plan options, and filed their products, when certifications and approvals are received, you’ll see all of those standard plans being displayed on healthcare.gov or any state-based exchange shopping environment.
With the changes that CMS put forth on standard plan options for 2025, we encourage carriers to think about their current standard operating procedure in place on how you delivered these plans and filed them this year, how they’ll be launched on healthcare.gov or any state-based marketplace for testing and or for shopping for your members, and encourage you to develop a process and procedure for 2026 and beyond.
I think now, putting aside some of the key provisions that CMS had an emphasis on quality and access to care for members, for a second, we can transition to some of the regulatory and key compliance efforts CMS is focusing on for next year as well, too.
When we think about how CMS is strengthening market regulations using such things as transparency and coverage as an example, it’s really interesting to think that CMS just released transparency and coverage, or the TIC template for short, no longer than two years ago.
So for carriers entering a market for the first time in 2025, they’re going to have to be able to furnish certain levels of information that they never had to before.
Thinking about why CMS has developed these new requirements even in the first place, some carriers must think, oh, well, they just have to have us populate a new template with the set of data.
What does that actually mean?
Well, using the TIC template as an example, carriers now have to furnish different levels of claim data that they never had to before to show transparency to both state divisions of insurance and the general public.
Part of strengthening health care regulations is also increasing transparency to the actual policies and procedures that are performed between the health plan and CMS and the federal government, something that’s been a big mystery and behind closed doors for many years before now.
Another challenge that CMS is looking at for 2025 to strengthen market opportunities is network adequacy.
Now we all know the time and distance standards were increased this year, which caused a lot of operational nuances for carriers, especially entering ECP data into the MPMS system or completing the network adequacy template compliantly and timely this year.
For those of you out there who are actually filing and close to the work, you’re probably actually still working on those objections right now as we speak, prior to certification.
Why is CMS changing all of these processes?
It’s really interesting, but often forgotten, that network and network adequacy is one of the biggest key drivers to offering a health plan in general.
If a carrier doesn’t have a robust or compliant network, they’ll never be able to offer a plan or serve a member in any geography within a state.
We encourage carriers to take all the knowledge that they learned through the 2025 release of Network Adequacy and really start to develop core policies and procedures internally to get ahead of future guidance in 2026.
We can assure you that adequacy will be at the forefront of the next NBPP release.
It’s really important to remember that the NBPP, while it has its most heavy focus on the Affordable Care Act and Qualified Health Plan specifically, it does have impact to certain product lines and healthcare lines of business such as Medicaid and CHIP.
Depending on what products you currently offer on your shelf, carriers may now be required to furnish different levels of reporting of certain CHIP and Medicaid data to CMS that never had been required to be provided before.
This may require your internal, operational or IT teams to develop new codes or new processes to pull certain data sets to submit to CMS that didn’t exist before.
That’s okay.
This is all in an effort to strengthen market standards and to increase transparency from carriers to CMS and the general public.
One of the last items that CMS focused on for market strengthening was risk adjustment provisions, and the ability to make sure members are compensated appropriately, especially ones at high risk or high risk of chronic conditions.
Risk adjustment has always been a big and also expensive process for carriers and insurers across the country, especially if you’re a new market entrant.
Harnessing the new regulations for risk adjustment early on will be very important, especially as the EDGE process gets kicked off this fall.
Take a look at who in your organization is responsible for actuarial delivery and also claims processing.
Those are the folks that are going to need to understand this rule inside and out.
So that being said, let’s talk about our recommendations for how you can be successful managing these policies and procedures.
We recommend if you don’t have any designated point of contacts in your organization that work with CMS or work with state divisions of insurance, you likely should appoint one.
Whether this is somebody from your government affairs organization, your legal team or even your product team would be a viable candidate for being a point of contact to receive this rule and implement it within your organization.
Starting this fall, what we would expect as you continue to attend the weekly REGTAP webinars is CMS will start to allude to a draft release date for the NBPP for 2026.
If we use the release date from last year as a baseline, we can expect that CMS will produce and furnish a federal rule or federal change, or a memo for issuers to review closer to November or December of this year.
We encourage you, if you haven’t already, to subscribe to CMS’ Public Federal Newsletter through the cms.gov website to ensure that you’re up to date with all real-time alerts, including NBPP newsletters.
Once you do receive the draft NBPP this year, if you haven’t seen it before, it’s a bit daunting.
The document this past release was over 600 pages long.
What CMS will likely do is they’ll publish the federal rule in the Federal Register, which will be the formal guidance that you can download and socialize with your internal teams, but they may also release an FAQ document alongside it.
Making sure all your right stakeholders are informed of any changes will be critical to the implementation of the new rule to make sure that your plans are compliant and efficient.
Once you do receive the draft, it’s normally segmented into a few different categories.
We recommend if you don’t have technology internal that manages your project management or your day-to-day operations, something as simple as an Excel spreadsheet or a Word document could do.
Parsing out each of the key categories on the spreadsheet will allow you to assign work item owners to then manage and collect feedback on what a policy change would mean for the organization.
Understanding that policy changes could mean something very different for a smaller carrier’s utilization management team as a larger carrier’s utilization management team, making sure that those sections are parsed out, identified and sent to the right subject matter expert for review and feedback will be crucial.
Your point of contact should then collect any feedback on these changes, whether it’s positive or negative, and start to build their own repository.
It’ll be very important for you to wrap a timeline around this, because CMS only allows one comment period for issuers to provide feedback on formal letterhead to form their position for plan year 2026.
As you chip away through the key categories, it’ll be important to aggregate and summarize all the information to formulate your letter.
Collecting the data is one thing, but formulating a position to CMS is another.
So once you do collect the necessary data and feedback from your internal subject matter experts, it will be important to align with your organizational leadership and executive team to understand: does the policy impact align with your plan and product strategy for the future plan year?
If not, you need to be very mindful of how you dictate your feedback to CMS when publishing your response letter.
Setting a target date internal in advance of the CMS publish due date for a letter will be important to allow your teams enough time to QA and QC and get all the necessary sign-offs before sending that letter out the door.
Once it goes out, there’s really no going back until the final NBPP is released the following January or February of that new plan year.
Once the draft comment letters and position letters are submitted in Q4 of this year, this will allow carriers about 2 to 3 months of preparation time before the final NBPP is released in that future plan year.
Now, you may be asking yourself, well, with all of the policy changes and the predictions from CMS, how do we actually make decisions on what to do next if we don’t have the final rule?
We recommend that you create 1 or 2 business strategies around some of the key policies and provisions, if they get passed into law, or if they don’t get passed into law to prepare for both scenarios, positive or negative, for your organization.
We don’t believe that this is a waste of time and resources for your teams, but a defensive mitigation strategy in case that a federal rule rules in favor or not in favor of your plan strategy or plan position.
At the end of the day, whether you’re a new market entrant or not, the NBPP is not going away and it’s something that carriers do need to plan for on an annual basis, regardless if you are participating within an FFM or an SBM marketplace.
That wraps us up for today.
Thanks everybody for listening in.
Give us a like, give us a share, and we’ll talk again next time.
