The Centers for Medicare & Medicaid Services (CMS) on Friday released the HHS Notice of Benefit and Payment Parameters (Payment Notice) for 2026 Proposed Rule, which outlines potential changes to the Affordable Care Act (ACA) marketplaces, as well as health insurance issuers, brokers, and agents who connect marketplace consumers to coverage.
The 278-page proposed rule, which is scheduled to be published in the Federal Register on October 10, includes changes to protect consumers from fraud and updates the HHS risk adjustment program. CMS will accept comments on the proposals through November 12.
Here’s a summary of five proposed changes:
Crackdown on agent, broker fraud
To reduce the risk of fraud or misconduct, CMS wants to expand its authority to suspend agents and brokers who pose an unacceptable risk to marketplace operations or marketplace information technology systems. The agency would end an agent or broker’s ability to transact information with the marketplace itself if it discovers circumstances that pose a risk to the accuracy of marketplace eligibility determinations, operations, applicants, and/or enrollees.
“This proposed policy would improve the security and integrity of marketplaces, resulting in fewer unauthorized changes to coverage and preventing further harm to consumers, agents, and brokers who follow the rules and comply with agency requirements,” CMS said.
Changes to risk adjustment model, RADV sampling
Among the proposals, CMS wants to:
· Use 2020, 2021, and 2022 benefit year enrollee-level EDGE data to recalibrate the 2026 benefit year HHS risk adjustment models.
· Update initial and second validation audits sampling to improve the precision of HHS-RADV results, which it uses to adjust risk scores and associated risk adjustment state transfers.
· Improve HHS-RADV’s actionable discrepancy and appeal threshold. CMS currently allows issuers to appeal HHS-RADV second validation audit results or error rate findings if the amount in dispute meets the materiality threshold for filing. The agency proposes a second materiality threshold of $10,000 for rerunning HHS-RADV results in response to an appeal. If finalized as proposed, HHS would only take action to adjust risk adjustment state transfers if the financial impact on the filing issuer’s HHS-RADV adjustment is greater than or equal to $10,000. CMS said this would result in more stable risk adjustment results for issuers and reduce administrative costs to the federal government.
Addresses when silver loading is allowed
Silver loading is a practice that issuers use to raise the cost of premiums for their silver plans to offset the cost of providing cost-sharing reductions that lower the amount consumers pay for deductibles, copayments, and coinsurance for other plans.
CMS is asking for public comment on whether the agency should codify its previous guidance that allows for certain silver-loading practices when the adjustments are reasonable, adequately justified, and follow state law. Enrollees who receive premium tax credits (PTCs) to cover all or part of their premium costs get more support through PTCs to cover higher premiums caused by silver loading, CMS noted.
Advance health equity, mitigate health disparities
CMS plans to allow issuers to either adopt a fixed-dollar premium payment threshold or a one or two percentage-based premium payment threshold to help enrollees keep their coverage when they fail to pay the full premium. CMS is proposing a cap of $5 for the fixed-dollar threshold to protect enrollees if they pay their first premium and then owe $5 or less after PTCs.
The proposals would allow plans to choose a method that works best for them and their consumers, CMS said. “Thresholds generally help to reduce terminations of coverage for enrollees–particularly people with low and modest incomes–who risk losing coverage when they fail to pay a small amount they might owe for their premium,” the agency said.
Increase transparency
CMS plans to release the annual State-based Marketplace Annual Reporting Tools and accompanying financial and programmatic audits (for state marketplaces and state-based marketplaces on the federal platform), as well as additional data points for all marketplaces. The agency said the actions would help enhance public understanding of and confidence in marketplace operations, ensure transparent compliance activities, and improve marketplace efficiency and accountability.
For more information, click here for a fact sheet and here for the proposed rule.