The Centres for Medicare & Medicaid Services (CMS) in the US has finalised a broad set of regulatory changes to the Affordable Care Act Exchanges for the 2027 plan year, combining lower federal user fees with stricter eligibility checks and a larger role for states in terms of oversight.
The measure, titled ‘Notice of Benefit and Payment Parameters for 2027; Basic Health Program’, sets out updates affecting enrolment controls, subsidy eligibility, plan certification and Exchange administration.
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A central part of the rule is the reintroduction of pre-enrolment checks for Special Enrolment Periods.
It also brings in extra income documentation requirements in some cases and updates the rules for advance premium tax credit eligibility to match provisions in the Working Families Tax Cut legislation.
The adjustments are intended to limit improper enrolments and direct federal subsidy support only to those who qualify.
The rule also sets out stricter oversight for insurance agents and brokers by defining barred marketing conduct more clearly and by standardising records used to document consumer consent and eligibility reviews.
For insurers using HealthCare.gov, the CMS is ending the requirement to offer standardised Qualified Health Plan (QHP) options and is removing caps on the number of non-standardised options they may sell.
The rule also creates a certification route for certain plans that operate without a provider network to qualify as a QHP.
The agency is also permitting catastrophic plans to be offered for as long as ten continuous plan years.
It is widening hardship exemption eligibility as well, allowing more people to enrol in catastrophic coverage.
Separate revisions to cost-sharing rules give insurers more flexibility in designing bronze and catastrophic products in the individual market.
States are given more discretion in supervising their Exchanges. The rule allows states to adapt certification reviews to local market conditions.
Federally facilitated Exchange states that satisfy federal requirements may choose to carry out their own provider access reviews and/or Essential Community Provider reviews, with CMS assistance if required.
The CMS is also removing the transition period for states shifting from a Federally facilitated Exchange to a State-based Exchange.
Further provisions address benefit design and filing requirements.
From the 2028 plan year, states must cover the cost of any mandated benefits that go beyond Essential Health Benefits (EHB), even if those benefits appear in the state’s EHB-benchmark plan.
The rule also bars issuers from treating routine non-paediatric dental services as an EHB.
In addition, insurers will face expanded disclosure requirements in rate filings, including details on how unreimbursed cost-sharing reductions are reflected.
Federal user fee rates are being lowered to 1.9% for the Federally facilitated Exchange and 1.5% for State-based Exchanges on the federal platform.
Those rates compare with 2.5% and 2%, respectively, in 2026. The CMS said the lower charges are expected to add downward pressure on 2027 premiums.
