Actuarial Value Calculator
CMS propose to only release a single, final version of the AV Calculator, instead of publishing a draft and a final version. Public comments would be implemented into the following year’s AVC. [20] This was finalized as proposed.
Standardized Plan Options
Standardized health plans were introduced to “enhance the consumer experience, increase consumer understanding, simplify the plan selection process, combat discriminatory benefit designs that disproportionately impact disadvantaged populations, and advance health equity.”[21]
As with all plans, standardized plan options will require adjustments to continue to be within the allowable AV range as the AV calculator is updated annually. Minor updates (deductibles and maximum out-of-pocket limits (MOOPs)) are proposed to the standardized plan options for PY2026 to keep the plans within the appropriate AV range. These were finalized with modifications to the expanded bronze plan designs, generally reducing member cost sharing where subject to deductible, although the final parameters were presented in Table 1 and Table 2 of the final rule.
HHS also reintroduced “meaningful difference” by requiring issuers that offer multiple standardized plan options within the same product network type, metal level, and service area to meaningfully differentiate these plans from one another. They indicated differences in product, network, and formulary as “meaningfully different,” similar to the 2017 Payment Notice. This was finalized with a minor modification where “an issuer that offers multiple standardized plan options within the same product network type, metal level, and service area must meaningfully differentiate these plans from one another in terms of included benefits, provider networks, included prescription drugs, or a combination of some or all these factors.” The primary difference being HHS noting a difference in prescription drugs would represent a meaningful difference as opposed to a different formulary ID. HHS further stated “For the purposes of this standard, a standardized plan option with a different product ID, provider network ID, drug list ID, or some combination of or all these factors, will be considered meaningfully different.”
Non-Standardized Plan Option Limits
In 2024 Payment Notice, HHS introduced a limitation on the number of non-standardized plan options as HHS believed the number of plan offerings was overwhelming for consumers with indistinguishable differences. They were permitted four (4) non-standardized plan options per product network type (as described in the definition of ‘‘product’’ at § 144.103), metal level (excluding catastrophic plans), inclusion of dental and/or vision benefit coverage. [22]
This was limited to two (2) non-standardized plan options for plan year 2025, however, HHS explained they failed to distinguish dental between pediatric and adult dental, so additional non-standardized can consider these separate categories. Additionally, HHS indicated further non-standardized plans can be available if they have “specific design features that would substantially benefit consumers with chronic and high-cost conditions and meet certain other requirements,” which typically means lower cost-sharing for certain services or drugs. Table 13 illustrates the plan variations.
[20] D. Part 156—Health Insurance Issuer Standards Under the Affordable Care Act, Including Standards Related to Exchanges – 5. AV Calculation for Determining Level of Coverage (§156.135)
[21] D. Part 156—Health Insurance Issuer Standards Under the Affordable Care Act, Including Standards Related to Exchanges – 6. Standardized Plan Options (§156.201)
[22] D. Part 156—Health Insurance Issuer Standards Under the Affordable Care Act, Including Standards Related to Exchanges – 7. Non-Standardized Plan Option Limits (§156.202)