Proposed Updates to Health Insurance Exchanges Regulations for 2027
On [Date], the U.S. Department of Health and Human Services (HHS), via the Centers for Medicare & Medicaid Services (CMS), unveiled a proposed rule aiming to update regulations for the 2027 plan year concerning Health Insurance Exchanges. This sweeping proposal targets regulatory compliance requirements for health insurance issuers and those facilitating consumer access to Affordable Care Act (ACA) coverage.
Key Provisions of the Proposed Rule
A core element of the proposed rule is enhancing regulatory consistency and oversight for ACA marketplaces. It touches upon payment parameters, including the risk adjustment program overseen by HHS, and sets user fees for issuers within Federally-facilitated Exchanges (FFEs) and State-based Exchanges on the Federal Platform (SBE-FPs).
Regulatory Enhancements and Oversight
The rule suggests stricter guidelines for marketing practices by agents, brokers, and web-brokers. These include forbidden practices and requirements for submitting marketing materials for audits. Furthermore, a State Exchange Improper Payment Measurement (SEIPM) program is proposed to manage improper payments, thus strengthening accountability across all Exchanges.
State Flexibility and Provider Access
States operating under FFEs may conduct their own provider access and Essential Community Provider (ECP) certification reviews, provided they meet established authority and capability criteria. Changes to Provider Network Standards are also suggested, such as reducing the minimum percentage of ECPs that issuers need to include in each plan’s service area.
Risk Adjustment and Financial Alignment
The recalibration of the HHS risk adjustment models for the 2027 benefit year is proposed, using updated enrollee-level data. Notably, the risk adjustment user fee rate remains steady at $0.20 per member per month, unchanged from the previous year.
Exchange Operations and Issuer Flexibility
The proposal includes eliminating the prerequisite for a State to operate as an SBE through a Federally-facilitated system before transitioning to a full State-based Exchange status. A State Exchange Enhanced Direct Enrollment model is also introduced, which permits the use of web-brokers for consumer enrollment processes.
Public Commentary
Public comments on this proposed rule can be submitted until March 11, 2026, with full details available in the Federal Register. Industry stakeholders are urged to provide feedback, particularly concerning risk model adjustments, state flexibilities, and issuer accountability standards. These changes aim to streamline operations, reduce costs, and maintain exchange integrity, aligning with ACA's objectives.