CMS Releases Proposed Exchange Guidance for 2026 

The Centers for Medicare and Medicaid Services (CMS) released its annual proposed guidance for Exchanges and Qualified Health Plans (QHPs) earlier than typical this year. As in prior years, the annual guidance includes the Proposed Notice for Benefit and Payment  Parameters for 2026 (NBPP) and the Draft Letter to Issuers on the Federally-facilitated Exchanges for 2026 (Letter), and addresses QHP certification standards, financial parameters, operational and technical guidance for Exchanges, QHPs, and premium stabilization programs, as well as standards for agents and brokers.    

As we do each year, our subject-matter experts have compiled an overview of the most significant changes outlined in the proposed NBPP and Letter to assist states as you prepare for the 2026 certification process. As outlined below, CMS is proposing significant changes to the standardized plan rules and the process for reviewing coverage of Essential Community Providers. In addition to the changes noted below, the guidance includes proposals related to standards for brokers and agents, Medical Loss Ratio standards, the Risk Adjustment Program, and the Basic Health Plan.  

Standardized Plans 

CMS proposed to amend the NBPP to state that in order to offer multiple standardized plan options within the same product type, metal level, and service area, the issuer must ensure that the plans are meaningfully different from one another. As part of this proposal, CMS is proposing to once again add a meaningful difference standard to the regulations. This standard would specifically apply to standardized plans since carriers are already limited in the number of non-standardized plans they can offer. In order to be considered meaningfully different, plans would need to have different: 

• • Benefits,  
  • Provider networks, and/or 
  • Prescription drug formularies. 

Two or more plans that do not meet that standard, would not both be certified. CMS also noted that additional standards for meaningful difference may be introduced going forward. 

CMS additionally proposed “minor updates” to the Federal standardized QHP plan options for plan year 2026 to ensure the plans continue to have actuarial values that follow within the allowed de minimis range for each metal level. The new plan designs can be found in tables 11 and 12 in the NBPP, which are included below. 

Essential Community Provider (ECP) Review Process 

Historically, CMS has relied upon states performing plan management functions to complete ECP certification reviews for QHPs. Due to recent system upgrades, the agency proposed to conduct Federal ECP certification reviews for QHPs in states that perform plan management functions beginning in PY 2026. Issuers in states performing plan management functions can now enter their ECP data into the Health Insurance Oversight System (HIOS) Marketplace Plan Management System (MPMS) using the ECP user interface. The interface software allows issuers to validate data before submission to states, likely improving data accuracy and streamlining the submission and certification process. This policy change would permit CMS more consistent oversight over the QHP certification process in states that perform plan management functions, in addition to ensuring that issuers seeking certification include sufficiently robust provider networks. 

Prescription drugs 

CMS proposed to phase out price adjustments to Hepatitis C drugs beginning in PY 2026, better aligning Hepatitis C drug costs with other similar specialty drugs. CMS also proposed to include pre-exposure prophylaxis (PrEP) services as a standalone factor in the adult and child 2026 risk adjustment models. 

User fees and SADP cost-sharing limitations 

CMS proposed to increase user fees to 2.5% of total monthly premiums for the Federally-facilitated exchange (FFE) and 2.0% of total monthly premiums for the State-based Marketplaces on the Federal platform (SBE-FPs). This would be a significant increase from recent years due to the potential sunsetting of the enhanced premium tax credit (PTC) subsidies in 2026. In the event that Congress extends the PTC subsidies by the end of March 2025, likely maintaining current high Marketplace enrollment, CMS proposed to set the FFE user fee rate range between 1.8 and 2.2% and the SBE-FP user fee rate range between 1.4 and 1.8%.  

Silver-loading  

Since the end of the Federal appropriation for cost-sharing reductions (CSRs), issuers have increased premiums – typically isolated to silver-level QHPs – to account for the cost of providing the required CSRs, in a practice known as “silver or actuarial loading.” CMS used the preamble of the proposed NBPP to reaffirm that carriers may apply the cost of providing CSRs to all QHPs or limit the cost to silver QHPs as long as the rate variation is “reasonable and actuarially justified.” CMS is considering codifying that guidance when it finalizes the regulations.