Key Changes for PY2025

The changes outlined below are not exhaustive and do not include changes to QHP Application templates or specific data entry requirements. Issuers should refer to the Published Guidance and Regulations webpage and review the most updated version of the QHP Issuer Application Instructions on the QHP certification website.

Non-Standardized Plan Option Limits and Exceptions

As was previously finalized in the HHS Notice of Benefit and Payment Parameters for 2024, in accordance with 45 CFR 156.202(b), in PY2025 and subsequent years, CMS will limit the number of non-standardized plan options that QHP issuers can offer through the Exchange (including SBE-FPs) to two per product network type, metal level (excluding catastrophic plans), inclusion of dental and/or vision benefits, in any service area. 

Additionally, in the HHS Notice of Benefit and Payment Parameters for 2025, CMS finalized an exceptions process at 45 CFR 156.202(d) through (e) that permits issuers to request to be excepted from the non-standardized plan option limit. For an issuer to be excepted from this limit, the issuer must demonstrate that the additional non-standardized plan options it desires to offer beyond the limit would substantially benefit consumers with chronic and high-cost conditions. Specifically, at § 156.202(d), for PY2025 and subsequent years, an issuer may offer additional non-standardized plan options for each product network type, metal level, inclusion of dental and/or vision benefit coverage, and service area if it 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 an issuer’s other non-standardized plan option offerings in the same product network type, metal level, and service area.

Additionally, as part of this exceptions process, at 45 CFR 156.202(e), an issuer that seeks to utilize this exceptions process is required to submit a written justification in a form and manner and at a time prescribed by HHS that demonstrates how the specific plan would substantially benefit consumers with the relevant chronic and high-cost condition. Issuers seeking to utilize this exceptions process must complete the Non-Standardized Plan Option Limit Exceptions (NSPOLE) justification within the Plans & Benefits application section of the HIOS MPMS Module. Refer to the Plans and Benefits webpage for more information.

Federal Hierarchy Modifications

All Exchanges (federal and state) will be required to re-enroll consumers with catastrophic coverage, including those consumers who will lose eligibility for catastrophic coverage. Additionally, an Exchange may not re-enroll enrollees of a non-catastrophic plan to a catastrophic plan. Both changes codify the current re-enrollment process of the federal Exchange. Refer to the Plan Crosswalk webpage for more information.

Changes to Data Submissions in MPMS

Starting in PY2025, issuers will experience changes to the process of submitting Essential Community Providers (ECP), Network Adequacy, and Plan ID Crosswalk data.

Submitting Essential Community Providers Data in MPMS

All issuers, including issuers in states performing plan management functions and SBE-FPs, will submit ECP data via the new ECP section within the Plan Attributes application group in the HIOS MPMS Module. In the new ECP application section, issuers will no longer submit these data in a template, but through a user interface by selecting providers from the available list and adding write-in providers as necessary. Issuers will then associate these providers to their applicable networks. Returning issuers will be able to follow prompts within the ECP application section to import the prior plan year’s provider data and then make any necessary modifications. Starting in PY2025, issuers will no longer submit an ECP Justification Form or the ECP Write-In Worksheet.  

Refer to the ECP webpage for more information. 

Submitting Network Adequacy Data in MPMS

All issuers, including issuers in states performing plan management functions and SBE-FPs, will submit Network Adequacy materials via the new Network Adequacy section within the Plan Attributes application group in the HIOS MPMS Module. Returning issuers will be able to navigate to the Application Materials tab in the HIOS MPMS Module to generate and download a prepopulated version of the Network Adequacy Template containing data imported from the prior plan year. Issuers will then make edits to the prepopulated template, validate, and link the template to their QHP Application before submitting. New issuers can download a blank template from the Network Adequacy webpage for completion and upload to the HIOS MPMS Module.

Refer to the Network Adequacy webpage for more information. 

Submitting Plan ID Crosswalk in MPMS

All issuers, including issuers in states performing plan management functions and SBE-FPs, will submit Plan ID Crosswalk data via the Plan ID Crosswalk section in the new Plan Crosswalk application group in the HIOS MPMS Module. Issuers will be able to generate and download a prepopulated Plan ID Crosswalk Template containing data imported from the prior plan year on the Application Materials tab in the HIOS MPMS Module. Issuers will then edit the template as needed and upload to the HIOS MPMS Module, where they will validate and link the template to their QHP Application. Within the new Plan ID Crosswalk application section, issuers must then run cross validation checks and provide any necessary justifications and evidence of state authorization before submitting. Issuers who are not returning to the Exchange no longer submit a Plan ID Crosswalk Template. 

Refer to the Plan Crosswalk webpage for more information.

SERFF Issuer Data Validation & Submission in MPMS

Issuers in states performing plan management functions and SBE-FPs will now be required to cross validate and submit QHP Applications to CMS in the HIOS MPMS Module, after states transfer application data from SERFF. Issuers will receive an email notification following successful transfer of data and must then navigate to the HIOS MPMS Module, complete and upload any additional materials, and then  submit all required application groups to CMS for review. When issuers submit groups in MPMS, cross validation checks will automatically run on the applicable data. If issuers have cross validation errors or warnings that require changes to applicable application templates, issuers will need to work with their state to retransfer data to the HIOS MPMS Module, so that the issuer can then submit the affected groups to CMS. QHP Applications will not be considered complete until issuers submit all required application groups relevant for each deadline in the HIOS MPMS Module. 

Refer to the MPMS Module User Guide and the Application Submission webpage for more information.