Final ACA Marketplace Rule Could Subtly Steer Plan Design Changes
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Jan 17, 2025
In the finalized version of the Biden administration’s last regulation governing the Affordable Care Act marketplaces, CMS made few changes from the version proposed in early October. Yet industry experts say it’s still worth flagging a few under-the-radar provisions that could have a lasting impact on how insurers design their plans — even amid a new presidential administration that will likely look to make its own impact on the exchanges.
In the 2026 Notice of Benefit and Payment Parameters (NBPP), which was finalized on Jan. 13, CMS cemented its proposal to incorporate HIV pre-exposure prophylaxis (PrEP) services into the 2026 risk adjustment models as a new, separate factor. Essentially, CMS had to create a class of predictor variables called affiliated cost factors (ACFs) to apply to PrEP, because it didn’t fit into the two other categories used in determining risk scores: the hierarchical condition category or the prescription drug category.
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