HHS Notice of Benefit and Payment Parameters for 2027 Proposed Rule
Introduction
Today, the U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), issued the proposed “Notice of Benefit and Payment Parameters” for the 2027 plan year (the 2027 Payment Notice proposed rule) that sets standards for the Health Insurance Exchanges, as well as for health insurance issuers, brokers, and agents who connect millions of consumers to Affordable Care Act (ACA) coverage.
The 2027 Payment Notice proposed rule contains provisions to improve implementation of the ACA, including payment parameters and provisions related to the HHS-operated risk adjustment and risk adjustment data validation (HHS-RADV) programs, as well as 2027 user fee rates for issuers offering qualified health plans (QHPs) through Federally-facilitated Exchanges (FFEs) and State-based Exchanges on the Federal platform (SBE-FPs).
This proposed rule also includes provisions related to the defrayal of state-mandated benefits; civil money penalties (CMPs) for noncompliant issuers and other responsible entities; strengthened standards of conduct for and administrative actions against noncompliant agents, brokers, and web-brokers; the expansion and codification of hardship exemption eligibility; implementation of the State Exchange Improper Payment Measurement (SEIPM) program; discontinuation of standardized plan option requirements and the non-standardized plan option limit and exceptions process; provider access and essential community provider standards for QHP certification; QHP certification of non-network plans; a prohibition on issuers from including routine non-pediatric dental services as an Essential Health Benefit (EHB); cost-sharing changes for catastrophic and individual market bronze plans; standards for multi-year contract terms for catastrophic plans and seeks comment on whether to apply similar standards to metal level plans; QHP issuer quality improvement strategies (QISs); revision to federal funding for certain individuals enrolled in the Basic Health Program (BHP); and seeks comment on potential adjustments to the Federal medical loss ratio (MLR) standard in the individual market. This proposed rule also includes updates needed to align regulations with changes made in Public Law (Pub. L.) 119-21, also known as the Working Families Tax Cut (WFTC) legislation.
The 2027 Payment Notice proposed rule can be accessed via the Federal Register at https://www.federalregister.gov/d/2026-02769. The deadline for submitting public comments is March 13, 2026.
Enhancing Program Integrity
Expand Regulations on Marketing Practices
CMS proposes to strengthen regulations on marketing practices for QHPs offered through Exchanges, as well as for agents, brokers, and web-brokers assisting consumers with enrollment in QHPs through the FFEs and SBE-FPs. This proposal includes examples of prohibited marketing practices, such as providing cash, monetary rebates, or cash equivalents to induce consumers to enroll; falsely asserting or suggesting that consumers will qualify for zero-dollar insurance or zero-dollar premiums; and miscommunicating enrollment timelines and deadlines. CMS also proposes requirements for timely production of marketing materials for monitoring, audit, or enforcement purposes. This proposal would ensure consumers are provided accurate information about the Exchange prior to enrollment, maintain the integrity of the Exchanges, and foster trust between consumers and agents, brokers, and web-brokers.
Mandating a Standard Eligibility Application Review Form and Consumer Consent Form
CMS proposes to require agents, brokers, and web-brokers to use the HHS-approved and created form to meet the eligibility application review documentation requirements and consent documentation requirements. CMS also proposes to clarify what types of actions constitute a consumer “taking an action” to review and confirm the accuracy of their information on their eligibility application and consent documentation. These proposals would protect consumers enrolling on the Exchanges from noncompliant agents, brokers, and web-brokers and protect consumers from inaccurate eligibility determinations, being enrolled in health coverage that does not meet their needs, and unexpected tax liabilities.
Implement and Apply the SEIPM Program
CMS proposes implementing a SEIPM program in calendar year 2027 to measure improper payments of advance payments of the premium tax credit (APTC) administered by State-based Exchanges (SBEs). CMS currently has a process in place to measure improper payments of APTC for the FFEs, but not one for SBEs. This proposal would ensure oversight of improper payments across all Exchanges, promoting consistency and parity in program integrity efforts nationwide. CMS further proposes to permit SBEs to satisfy certain requirements of the independent external programmatic audit by completing the SEIPM process.
Empowering States and Enhancing Qualified Health Plan Certification Flexibilities
Provider Access and Essential Community Provider (ECP) Certification Reviews
CMS proposes that FFE states may elect to conduct their own provider access reviews and/or ECP certification reviews of issuers’ plans, with or without a provider network, that apply for QHP certification to be offered through a FFE(including states that perform plan management), provided that CMS determines the state has sufficient authority and the technical capacity to conduct such reviews by satisfying the applicable criteria to be considered to have an Effective Provider Access Review Program for provider access certification reviews, and/or an Effective ECP Review Program for ECP certification reviews. A FFE state would have the choice to elect to conduct their own provider access certification reviews, ECP certification reviews, or both reviews provided the FFE state satisfies the applicable criteria for each effective review program it wishes to administer. CMS also proposes to continue collection of provider access and ECP data from all issuers with or without a provider network across FFE states, regardless of whether the FFE state or CMS is conducting certification reviews, in an effort to extend our existing infrastructure to monitor consumer access to a sufficient choice of providers across the FFE and to provide technical assistance to states, including FFE states that seek to expand their own technical capacity to conduct their own reviews in future plan years. If an FFE state does not elect to conduct its own reviews or is not determined by CMS to have an Effective Provider Access Review Program and/or Effective ECP Review Program, as applicable, then CMS would continue to perform such reviews of QHP issuers with and without a provider network.
In addition, CMS proposes to restore aspects of network adequacy authority back to the SBEs and SBE-FPs through the removal of requirements for SBEs and SBE-FPs to establish and implement quantitative time and distance standards that are at least as stringent as those for QHPs participating in the FFEs by 2026. Instead, states would be required to ensure that each QHP applying for certification to be offered through a SBE or SBE-FP provides sufficient choices of providers in a manner that meets applicable standards specified in § 156.230(a)(1)(ii) and (iii) for network plans, or § 156.236(a) for non-network plans.
These proposed policies recognize that states often possess unique knowledge of local factors including on market conditions, geographic constraints, provider shortages, and population demographics. In addition, these proposals recognize State certification reviews may benefit from using the provider access data CMS currently collects. Empowering FFE States to tailor their certification reviews to the needs of consumers in their state with this data resource may strengthen reviews and improve the consumer experience. The proposal also would reduce regulatory burden on issuers participating in the Exchange and address concerns raised about duplicative state and federal oversight processes.
ECP Standards and Requirements
CMS proposes revising the minimum percentage of ECPs that issuers must contract with in each plan’s service area to participate in the plan’s provider network from 35 percent to 20 percent, applicable to the overall ECP threshold and, separately, to the federally qualified health center (FQHC) and family planning provider thresholds. CMS also proposes to remove the narrative justification requirement to be consistent with systems changes and existing QHP issuer ECP data submission requirements as part of ECP certification reviews. These proposed policies would potentially reduce regulatory burden on QHP issuers and provide such issuers with more resources that they can leverage for other activities, such as innovating plan offerings or passing on savings to consumers, while ensuring ECPs are included within an issuer’s provider network consistent with the requirements of the ACA.
QHP Certification of Non-Network Plans
CMS proposes to allow non-network plans to receive QHP certification beginning with plan year 2027 by demonstrating a sufficient choice of providers in a manner consistent with sections 1311(c)(1)(B) and (C) of with the ACA. Unlike network-based plans, non-network plans do not rely on a contracted set of providers that agree in advance to specific terms and negotiated payment rates, nor do they condition or differentiate benefits to enrollees based on whether the issuer has a network participating agreement with a provider that furnishes covered services. Instead, these plans set specific benefit amounts for covered services and communicate those benefit amounts to enrollees who may then seek covered services from any provider.
