On October 10, 2024, the Centers for Medicare and Medicaid Services (CMS) released the proposed Notice of Benefit and Payment Parameters (NBPP) for Plan Year (PY) 2026. The comment period is open through November 12, 2024. The NBPP outlines key policies and parameters that govern the operation of the Federally Facilitated Exchange (FFE), State-Based Exchanges using the Federal Platform (SBE-FP), and various operations for states operating as a State-Based Exchange (SBE). 

This NBPP includes information on a wide range of topics, such as the annual Open Enrollment Period, premium rates, cost-sharing requirements, the types of health plans that will be available, and other adjustments or additions to existing regulations or processes. The NBPP also sets guidelines for insurers participating in the Marketplace, including rules around network adequacy, essential health benefits, and consumer protections. The changes within the NBPP generally go into effect January 1 of the upcoming year. In some cases, changes may go into effect earlier or later than January 1 of the upcoming year. Any changes that have a different effective date than January 1, 2026, are specified below with the associated change. 

This blog post takes a look at various changes within the final rule that are impactful to SBE operations. 

Fraudulent Enrollments and Program Integrity

CMS proposes to amend section 1313(a)(5)(A) to reduce fraudulent enrollments and improve program integrity. In response to over 200,000 complaints about unauthorized enrollments and plan switches linked to unethical brokers and agents, CMS proposed several actions to enhance the FFE, including: 

  • Clarifying its authority to hold both individual brokers and their agencies accountable 
  • Tightening control over broker actions that pose an “unacceptable risk” 
  • Updating consent documentation practices 

CMS seeks feedback from state insurance departments to improve federal-state collaboration on oversight and enforcement. 

The GetInsured platform is built fundamentally differently and more securely than the FFE, as demonstrated by the following existing platform features: 

  • Agent Designation: The GetInsured system requires a two-step designation process, where the consumer initiates the designation and the broker accepts it, ensuring that only authorized brokers can act on behalf of consumers. 
  • Consumer Notifications: Consumers receive notice any time an agent or assister completes activities such as new enrollments or plan changes (as part of the 25.3 release). 
  • Activity Tracking: The system monitors application completion, enrollments, and enrollment changes providing states with the ability to identify unusual activity patterns through reporting that may indicate inappropriate conduct. 

GetInsured is in the process of developing platform enhancements that could assist in further monitoring agent and agency behaviors. These features are designed to help prevent unauthorized enrollments or plan changes and support investigations by tracking overall activity volume, issuing alerts for sudden trend changes, generating daily reports on unauthorized enrollment complaints with alerts to the state for excessive complaints, monitoring self-designation volumes with thresholds for alerts, and tracking applications submitted by agents without an SSN and $0 premium enrollments. 

Enrollment Data Corrections

CMS proposes to codify recent SBE guidance related to CFR 156.1210(a)(b) to clarify the timeline by which an SBE must adjudicate and report enrollment corrections to CMS. CMS proposes that SBEs must submit resolutions of enrollment data inaccuracies to CMS via the State Based Marketplace Inbound File (SBMI) within 60 days of receiving the inaccuracy report from an SBE Issuer. This timeline aims to ensure SBEs review and resolve data inaccuracies promptly to facilitate accurate Advance Premium Tax Credits (APTC) payments. Should the rule be finalized CMS may adjust the State Based Marketplace Annual Reporting Tool (SMART) to track compliance with the 60-day requirement by having SBEs detail their resolution process. 

Premium Payment Thresholds

CMS proposes modifications to CFR 155.400(g) to allow issuers to adopt a fixed-dollar premium payment threshold of up to $5, adjusted for inflation, to offer issuers flexibility in avoiding grace periods or enrollment termination for minor unpaid amounts. It also considers modifying the existing percentage- based premium threshold to use a gross premium basis, which would include the total premium rather than just the enrollee’s portion post-APTC. The modification is aimed at reducing coverage terminations for low- or moderate-income enrollees by allowing leniency for small unpaid premiums. The fixed-dollar threshold would only apply after coverage is effectuated, not for binder payments. CMS seeks feedback on whether a $5 threshold is appropriate or if a $10 alternative would be better. The proposal discourages using both fixed-dollar and percentage-based thresholds to prevent complexity. 

Qualified Health Plan (QHP) Certification Standards

CMS seeks to amend CFR 155.1000 by adding a paragraph that allows an SBE to deny certification of any health plan as a Qualified Health Plan (QHP) that does not meet the general certification criteria. This change would formalize the authority of an SBE to deny certification of any plan that does not meet the criteria. The proposal is not intended to require SBEs to implement any specific procedures or processes for the denial of a QHP certification application; it is instead intended to make the authority to do so more explicit. 

Program Integrity and Oversight Requirements

CMS proposes that in addition to collecting SBE information and data currently submitted through annual GAGAS financial audits, SMART submissions, and programmatic audits they will publicly release this information and any related documents of corrective actions or open findings. CMS also intends to expand on the SBE Open Enrollment data currently published by including additional metrics that are already collected, but not made public. This includes SBE outreach spending, eligibility and enrollment policies and processes, plan certification requirements, operational performance data including call center metrics (call center volume, average wait time, average call abandonment rate), and website visits and visitors. 

Insurer Insolvency Risk

CMS seeks comments on how to increase its coordination with state insurance departments and the National Association of Insurance Commissioners (NAIC). CMS proposes several ways to enhance coordination, including methods to implement interventions like limiting enrollment or denying QHP certification. Although CMS acknowledges that states are best positioned to manage these responsibilities, it seeks to partner with states to help assess the risks of certifying plans that might lead to insolvency, while ensuring that any actions taken will not interfere with SBEs. 

FFE and SBE-FP User Fee Rates for 2026 Benefit Year

CMS proposes a user fee for FFE states at 2.5 percent of total monthly premiums and an SBE-FP user fee rate of 2.0 percent of total monthly premiums. These increased rates are proposed as a safeguard against any inaction by Congress to extend enhanced APTC subsidies into 2026. However, if Congress extends the subsidies prior to issuer rate setting deadlines for the 2026 benefit year, CMS would revise its user fee rates closer to those in 2025 – between 1.8 percent and 2.2 percent for FFE states and 1.4 percent to 1.8 percent for SBE-FP states. 

Silver Loading Codification

CMS proposes to codify silver loading policies by amending CFR 156.80(d)(2)(i) to clarify that plan-specific factors by which issuers adjust the market-wide index rate include adjustments that reflect the costs associated with providing CSRs to the eligible enrollee population, to the extent that such adjustments are reasonable and actuarially justified. 

Standardized Plan Options

In 2023, CMS introduced standardized plan options for the FFE and SBM-FPs to simplify plan comparisons. Since then, CMS has made only minor adjustments to these plans to maintain their actuarial values. For the 2026 draft Payment Notice, CMS proposes to amend CFR 156.201 to make modest plan changes and the reintroduction of the meaningful difference standard, which requires insurers offering multiple standardized plans to ensure distinct differences in benefits, provider networks, or formularies to reduce consumer confusion – a practice discontinued by the previous administration in 2019. 

Additionally, CMS limits non-standardized plan options to two in the following categories: product network type, metal level, inclusion of dental and/or vision benefits, and service area. CMS will allow exceptions for plans offering significant benefits for those with chronic and high-cost conditions. CMS also addresses distinctions between adult and pediatric dental benefits in non-standardized plans, aligning with operational realities. 

Quality Improvement Strategies

CMS proposes to leverage CFR 156.1130 to share aggregated, summary-level Quality Improvement Strategy (QIS) information publicly on an annual basis beginning on January 1, 2026, with information QHP issuers submit during the Plan Year (PY) 2025 QHP application period. CMS intends to publicize this data for FFE states and encourage SBE states to share QIS information publicly via their state exchanges. 

Consumer Appeals

CMS proposes to amend CFR 155.505(b) to allow the enrollee’s application filer (family member or authorized representative) to submit appeal requests on behalf of applicants and enrollees. This change would apply to FFE and SBE states.  

Failure to Reconcile

CMS proposes to amend CFR 155.305(f)(4) to require Exchanges to notify enrollees or tax filers who have failed to file and reconcile their Advance Premium Tax Credits (APTC) for two consecutive tax years. Previously, enrollees could be deemed ineligible for APTC after two years of non-compliance, but notices were not mandatory. The 2026 Payment Notice introduces a requirement for either a direct notification specifying the failure or an indirect notice cautioning potential APTC loss and educating on compliance, ensuring notices are sent at least twice: once after the first year of failure and again after the second. These notifications aim to maintain APTC eligibility by ensuring tax filers and enrollees are informed of their filing requirements and potential risks. Exchanges on the federal platform are encouraged to follow best practices by providing multiple notifications, while SBEs are also required to enhance communication efforts to inform enrollees and/or tax filers of the risks pertaining to the failure to file and reconcile.