The Centers for Medicare and Medicaid Services (CMS) has issued the notice of benefit and payment parameters for 2026 proposed rule, which outlines important changes affecting health plans on the Affordable Care Act (ACA) marketplace. These proposals aim to refine enforcement mechanisms, improve consumer protections, and update various operational standards for health plans, marketplaces, and entities that assist consumers in navigating the health insurance system.
A major focus of the proposed rule is enhancing CMS’s enforcement efforts by introducing new safeguards to protect patients and marketplace operations. The rule also proposes allowing health plans to adopt a fixed-dollar payment threshold of $5 or less, adjusted for inflation, below which a grace period would not be triggered for enrollees who underpay their premiums. This provides enrollees with a cushion against minor payment discrepancies. Other proposed changes involve increasing user fees for the federally facilitated marketplace to 2.5% of monthly premiums and for state-based marketplaces on the federal platform to 2.0%. Adjusting the premium adjustment factor (PAF), recalibrating risk adjustment models, and moving the net risk adjustment amount in the medical loss ratio (MLR) calculation are also addressed in the proposed rule.
CMS is also requesting feedback on several policies, including approaches to address “silver loading” (when health plans increase premiums for silver plans to cover the cost of reduced cost-sharing payments) and the effects of the time value of money, which is the potential for capital to generate interest when invested, on the HHS-operated risk adjustment program.
More information is available in the CMS fact sheet, “HHS Notice of Benefit and Payment Parameters for 2026 Proposed Rule.”
AASM members can direct questions regarding the proposed rule to coding@aasm.org.
