What’s Changing – and What Hasn’t Changed – on the ACA Marketplace? Part 3: Notice of Benefit and Payment Parameters for 2027 Final Rule

• Home
• Articles

What's Changing - and What Hasn't Changed - on the ACA Marketplace? Part 3: Notice of Benefit and Payment Parameters for 2027 Final Rule

Hill to the Heartland: Federal Health Policy Briefing

This three-part blog series summarizes the changes affecting eligibility for marketplace enrollment and advance premium tax credits, as well as selected other changes relevant to the health insurance marketplace, and provides an update on their current status.

• Part 1 focuses on the statutory changes affecting the marketplace in H.R. 1.
• Part2 focuses on the status of the 2025 Marketplace Integrity and Affordability Final Rule.
• Part 3 focuses on the status of the Notice of Benefit and Payment Parameters for 2027; Basic Health Program Final Rule, issued in 2026.

When referring to types of marketplaces in the final rules, KHI uses the term "marketplace" or "exchange" as they are used in the provisions of the Affordable Care Act and by the Centers for Medicare & Medicaid Services, U.S. Department of Health and Human Services.

Hill to the Heartland: Federal Health Policy Briefing is a product series providing regular updates on federal health policy discussions. Sign up here to receive these summaries and more, and also follow KHI on Facebook, X, LinkedIn and Instagram.

Court Decisions Reshape Marketplace Rule

The Centers for Medicare & Medicaid Services, Department of Health and Human Services (CMS/HHS) issued the Notice of Benefit and Payment Parameters for 2027; Basic Health Program Final Rule on May 15, 2026. The final rule introduces changes to marketplace enrollment eligibility and advance premium tax credits (APTC), while also addressing several other marketplace-related provisions.

This blog, the final installment in a series of three, examines changes finalized for plan year (PY) 2027 and beyond in the Notice of Benefit and Payment Parameters; Basic Health Plan for 2027 Final Rule. The blog examines which provisions have been stayed (put on hold) by a federal court, and what the current status means for Kansans.

Changes, Stays and Remaining Provisions

On July 16, 2026, the U.S. District Court for the District of Maryland, in the case of City of Columbus, et al. v. Kennedy, et al. (Columbus II) granted a stay of eight challenged provisions of this Final Rule. Other provisions were effective July 20, 2026.

Removal of the Low-Income Special Enrollment Period Beyond PY 2026

To align regulations with Section 71304 of H.R. 1, this policy continues to prohibit exchanges from offering a Special Enrollment Period (SEP) after PY 2026 for individuals with incomes below 150 percent of the federal poverty level (FPL).

Pre-Enrollment SEP Verification (stayed)

Would require consumers using the federal exchange to verify SEP eligibility before enrolling. This policy, first established in June 2025, would allow for exchanges to conduct verification for additional SEPs beyond loss of minimum essential coverage and require exchanges to verify 75 percent of new SEP enrollments. This provision in the 2025 Marketplace Integrity and Affordability Final Rule was initially stayed and ultimately vacated by the Maryland federal district court in the Columbus I case as described in the second blog in this series.

Limiting APTC Eligibility to "Eligible Noncitizens"

To align with Section 71301 of H.R. 1, requires exchanges to verify the immigration status of applicants to receive APTC or cost-sharing reduction (CSR) subsidies, beginning with plan years on or after Jan. 1, 2027.

Disallowing APTC for Individuals Ineligible for Medicaid Due to their Immigration Status and Household Income Below 100 Percent of FPL (stayed)

To align with Section 71302 of H.R. 1, removes the requirement that, if all other APTC eligibility criteria are met, an exchange must determine a tax filer eligible for APTC if the exchange determines that the individual is expected to have an annual household income of less than 100 percent of FPL for the benefit year for which coverage is requested and they are a noncitizen who is lawfully present and ineligible for Medicaid due to their immigration status.

Income Verification When Tax Data is Unavailable (stayed)

Would remove the requirement for exchanges to accept a household's income attestation when the IRS returns no data for the household, a provision that was initially finalized in the 2025 Marketplace Integrity and Affordability Final Rule. Under the stay, exchanges will not be required to generate data matching issues for APTC applicants if federal data sources indicate that the applicant's income is below 100 percent FPL. This policy was also stayed and ultimately vacated in the 2025 Marketplace Integrity and Affordability Final Rule in the Columbus I case as described in the second blog of this series.

Failure to File and Reconcile (stayed)

Would require that, beginning with PY 2028, all exchanges must determine a tax filer or their enrollee ineligible for APTC if: (1) HHS notifies the exchange that the tax filer (or either spouse if the tax filer is a married couple) received APTC for a prior year for which tax data will be used to verify income, and (2) the tax filer did not file a federal income tax return and reconcile APTC for that year. Exchanges on the federal platform, including the Kansas marketplace, would have adopted the one-year policy for PY 2027. On July 27, 2026, CMS acknowledged the federal district court's rulings in both Columbus I and II and, for PYs 2026 and 2027, directed exchanges to "update their systems to stop removing or denying advance payments of the premium tax credit for any new applicants or existing enrollees due to having failed to file and reconcile prior years' premium tax credits" and noted that previous guidance that made a tax filers ineligible for APTC if they failed to file returns and reconcile their APTC for two years was no longer valid. (This policy was also stayed and ultimately vacated in the 2025 Marketplace Integrity and Affordability Final Rule in the Columbus I case as noted above.)

Expanded Regulations on Marketing Practices

For PY 2026, implements stronger regulations on marketing practices for agents, brokers and web-brokers assisting consumers with enrollment in health plans through federally-facilitated exchanges (FFEs) and state-based exchanges (SBEs) using the federal platform. Examples of prohibited marketing practices include providing cash, monetary rebates or cash equivalents to induce consumers to enroll; falsely asserting or suggesting that consumers will always qualify for zero-dollar insurance or zero-dollar premiums; and miscommunicating enrollment timelines and deadlines.

Standard Eligibility Application Review and Consumer Consent Forms

Requires agents, brokers and web-brokers to use HHS-approved and created forms to meet eligibility application review documentation and consumer consent documentation requirements. Agents, brokers and web-brokers will be required to use these forms for enrollments for plan years beginning on or after Jan. 1, 2028. Also clarifies 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.

Qualified Health Plan Certification of Non-Network Plans (stayed)

Effective beginning in PY 2028, would allow issuers offering non-network plans to receive certification to be offered as a qualified health plan (QHP) through the FFEs by demonstrating a sufficient choice of providers in a manner consistent with certain sections of the Affordable Care Act (ACA). Non-network plans do not rely on a contracted network of providers with negotiated payment rates, nor do they condition or differentiate benefits based on whether the issuer has a contractual agreement with a provider for covered services. Non-network plans would be required to ensure access to a range of providers that accept the non-network plan's benefit amount as payment in full, including essential community providers (ECPs) and providers that specialize in mental health and substance use disorder services, to ensure that services will be accessible without unreasonable delay. Non-network plans would be required to report certain information to the exchange to ensure the plan provides access to a sufficient choice of providers and promotes consumer protections.

Expansion of Hardship Exemption Eligibility for Enrollment in Catastrophic Plans (stayed)

Would allow individuals who are ineligible for APTC or CSR subsidies due to projected household income below 100 percent or above 250 percent FPL to qualify for a hardship exemption to enroll in catastrophic coverage when they experience a change in their household income. HHS had previously published guidance in September 2025 that expanded eligibility for a hardship exemption to individuals ineligible for APTC or CSR subsidies due to projected household income for consumers in FFEs, state-based marketplaces using the federal platform, and SBEs that delegate their exemption processing to HHS. This new policy would expand this hardship exemption to individuals in all states so individuals eligible for the exemption may enroll in catastrophic coverage, if otherwise eligible.

Aligning Affordability and Coverage Incentives Between Catastrophic and Metal Level Health Plans (stayed)

Would set standards under which catastrophic plans may have terms of up to 10 plan years. Multi-year catastrophic plans would be allowed to provide pre-deductible coverage through value-based insurance designs that incentivize consumers to receive higher-value services at lower cost, pursuant to guidelines issued by HHS and the Departments of Labor and the Treasury. Also, would change permissible cost-sharing parameters for bronze plans beginning in PY 2027 and update cost-sharing requirements for catastrophic plans beginning in PY 2028. Under the stay, all bronze plans must meet the cost-sharing and levels of coverage requirements, including meeting the standard annual limitation on cost sharing. Issuers are prohibited from offering bronze plans with out-of-pocket maximums that exceed the statutory limit.

Discontinuation of Requirement to Offer Standardized Plan Options and Limits on Non-Standardized Plan Options (stayed)

Would discontinue (1) the requirement for FFEs to offer standardized plan options in the individual market, (2) the differential display of these plans on HealthCare.gov and Direct Enrollment platforms, (3) the limit on the number of non-standardized plan options that may be offered by issuers, and (4) the related non-standardized plan option limit exceptions process. CMS would permit issuers to choose whether to discontinue existing standardized plan options and the chronic and high-cost conditions plans originally offered through the non-standardized plan option limit exceptions process or continue offering them, with either the same or modified cost sharing.

Provider Access and Essential Community Provider (ECP) Certification Reviews (stayed)

Under the ACA, issuers of qualified health plans (QHPs) are required to have a sufficient number and geographic distribution of ECPs in their service areas to ensure reasonable and timely access to care for low-income, medically underserved populations. ECPs include safety-net providers such as federally qualified health centers, community health centers, family planning clinics, hospitals in health professional shortage areas and Indian Health Service providers. Under this final rule, FFEs would be able to 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 the exchange, provided that CMS determines the state has sufficient authority and 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.

If a state does not elect to conduct its own reviews or is not determined to have effective certification review programs, then CMS would continue to perform such reviews of issuers with and without a provider network. If this provision were to take effect and Kansas were to elect to conduct its own reviews, the Kansas Department of Insurance would likely perform this function on behalf of the state.

Prohibiting Routine Non-Pediatric Dental Services as an Essential Health Benefit (EHB)

Beginning with PY 2027, prohibits issuers from including routine non-pediatric (adult) dental services as an EHB, as defined by the ACA.

Defrayal of Cost of State-Mandated Benefits

Revises states' responsibilities when mandating benefits that are considered "in addition to EHB." Beginning with PY 2028, any state-required benefit will be considered "in addition to EHB" - and thus not EHB - if it is required by state action after Dec. 31, 2011, applies to the small group and/or individual markets, is specific to required care, treatment or services, and is not mandated for compliance with federal requirements. Under this policy, states will be required to defray the cost of these additional benefits for enrollees in QHPs, regardless of whether the benefit is embedded in the state's EHB-benchmark plan. This policy requires that the cost of state-required benefits in addition to EHB is defrayed by states - not passed on to consumers through higher premiums or to the federal government through increased APTC payments.

Looking Ahead

Following the Maryland federal district court's orders in both of the City of Columbus, et al., v. Kennedy, et al. cases (Columbus I and II), striking several provisions of the 2025 Marketplace Integrity and Affordability Final Rule and staying provisions of the Notice of Benefit and Payment Parameters for 2027 Final Rule, CMS has issued guidance and an updated timeline for submissions for issuers as they prepare to submit their qualified health plan applications for Plan Year 2027. The Columbus II case is proceeding with additional pleadings due in late August.

Successful appeals of the federal district court's orders vacating and staying various provisions of these final rules, combined with the expiration of the enhanced premium tax credits at the end of 2025, could continue to reduce enrollment in all ACA marketplaces if current enrollees and other new consumers are unable to meet the new eligibility requirements or qualify for advance premium tax credits to reduce their monthly costs. KHI will continue to monitor both Columbus cases, and other new or pending litigation, and report on their outcomes and impacts on the operation of the Kansas marketplace and the enrollment of Kansans for PY 2027 and beyond.

Stay tuned for further updates on policy shifts that may affect health programs and services in Kansas. For related work on how federal policies could impact Kansans, please check out Hill to the Heartland.