2025 healthcare rules include positive changes, but lack key patient protection
The Patient Access Network (PAN) Foundation is pleased that the Centers for Medicare & Medicaid Services (CMS) finalized rules this month that expand prescription medication coverage and access to dental care, but were disappointed that once again, CMS declined to restrict copay accumulator programs that harm patients across the country.
“We’re thrilled about the changes that will increase access to medications and dental care, but seeing another year go by without addressing copay accumulators is hugely disappointing,” PAN Foundation Chief Mission Officer Amy Niles said. “The courts have ruled that health plans must include copay assistance in patient-cost-sharing, but we still need federal regulation to ensure this ruling is enforced. Until then, patients remain at risk.”
Each year, CMS proposes, reviews, and eventually finalizes the rules and regulations that guide the operation of the federal healthcare Marketplace. CMS issued the final 2025 Notice of Benefits and Payment Parameters (NBPP) on April 2.
Expanded prescription access
Each year, every state selects a benchmark plan that outlines the minimum coverage plans must provide. Previously, if a health plan included prescriptions that went beyond the state’s benchmark plan, the health plan could still label them as non-essential. When drugs are deemed non-essential health benefits, Affordable Care Act (ACA) cost-sharing protections don’t apply, and patients pay more out of pocket for their medications. Cost-sharing includes deductibles, coinsurance, copayments, and similar charges.
The 2025 rule means that if plans include prescriptions that go beyond the benchmark plan, then those medications must also be considered essential health benefits and covered by the plan.
The PAN Foundation and other patient advocates asked for this protection to be extended to large group and self-funded plans, and CMS has said that a new rule “to further strengthen the consumer protections in the ACA” is forthcoming for the U.S. Departments of Health and Human Services, Labor, and Treasury.
Expanded dental coverage
The NBPP also removes a regulatory barrier for coverage of adult dental services, allowing states the option to offer these services as part of an essential health benefit package in their benchmark plans. Importantly, this change aligns state benchmark plans more closely with the private marketplace. It also gives states the opportunity to improve adult oral health and overall health outcomes, which could help reduce health disparities and advance health equity.
No rules enforcing court ruling to make all copays count
Unfortunately, CMS is not requiring pharmacy benefit managers and insurers to count copay assistance payments made by or on behalf of an enrollee toward that enrollee’s annual deductible and out-of-pocket limit.
A recent U.S. District court ruling directed CMS to revert to the 2020 Notice of Benefit and Payment Parameters Rule. Thanks to this court decision, as of September 29, 2023, all copay assistance should now count toward a patient’s deductible, coinsurance, copays, and annual cost-sharing limits.
The rule has one exception though: it only applies to brand-name medications that have an equally effective generic equivalent. This means, if you opt for a brand-name medication that has a suitable generic equivalent, your copay assistance may not count towards your deductible and annual limit.
CMS is not requiring pharmacy benefit managers and insurers to count copay assistance payments made by or on behalf of an enrollee toward that enrollee’s annual deductible and out-of-pocket limit.