2025 Notice of Benefit & Payment Parameters 

The agencies released finalized 2025 Benefit and Payment Parameters regulations. The guidance generally focuses on the administration of the public Marketplaces, but also provides significant clarification on coverage requirements for prescription drugs. The regulations require that any prescription drugs covered in excess of the minimum number of drugs required to be covered under a state’s benchmark plan are required to be covered as essential health benefits (EHBs) unless the coverage is provided solely to comply with a state coverage mandate. This means that prescription drugs covered under a group health plan cannot be categorized as non-EHB subject to annual or lifetime dollar limits or excluded from maximum out-of-pocket limits. While the guidance is focused primarily on coverage requirements for non-grandfathered individual and small group fully-insured plans, a corresponding FAQ suggests additional guidance is coming that will extend similar rules to large fully-insured group health plans and all self-funded group health plans. 

 The final regulations can be found here – https://www.cms.gov/files/document/cms-9895-f-patient-protection-final.pdf 

The corresponding agency FAQ, Part 66 can be found here – https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/faqs/aca-part-66