Consistent with the clarification provided in the 2025 Payment Notice, HHS proposes an issuer may offer additional non-standardized plan options for each:
- product network type,
- metal level,
- inclusion of adult dental benefit coverage,
- pediatric dental benefit coverage, and/or
- adult vision benefit coverage
This was finalized as proposed except “and/or” was changed to “and”, so an issuer may offer additional non-standardized plan options for each:
- product network type,
- metal level,
- inclusion of adult dental benefit coverage,
- pediatric dental benefit coverage, AND
- adult vision benefit coverage
Additional plans for specific chronic and high-cost conditions will continue to be able to be offered if an issuer demonstrates: “that these additional plans’ cost sharing for benefits pertaining to the treatment of chronic and high-cost conditions (including benefits in the form of prescription drugs, if pertaining to the treatment of the condition(s)) is at least 25 percent lower, as applied without restriction in scope throughout the plan year, than the cost sharing for the same corresponding benefits in the issuer’s other non- standardized plan option offerings in the same product network type, metal level, inclusion of adult dental benefit coverage, pediatric dental benefit coverage, and/or adult vision benefit coverage, and service area.”
Essential Community Provider (ECP) Reviews
An Essential Community Provider (ECP) certification criteria refers to the requirements that QHPs include “within health insurance plan networks those ECPs, where available, that serve predominately low-income, medically- underserved individuals.” [23]
HHS is proposing to conduct Essential Community Provider (ECP) certification reviews in FFEs for states performing the plan management functions. ECP data has been submitted for review in the ECP/Network Adequacy (ECP/NA) template, which is submitted directly to HHS when the state is not performing plan management functions. However, if the state is performing the plan management functions, they are submitted to SERFF and system limitations have caused HHS to not be able to receive reliable data. HHS believes their recent system improvements (specifically the Marketplace Plan Management System (MPMS) allowing HHS to collect ECP data) will now allow them to conduct reviews beginning with plan year 2026. This was finalized as proposed.
[23] D. Part 156—Health Insurance Issuer Standards Under the Affordable Care Act, Including Standards Related to Exchanges – 8. Essential Community Provider Reviews for States Performing Plan Management (§156.235)