CMS Releases Final Exchange Guidance for 2026 

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    Lisa Kaplan Howe

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    Eliza Mette

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    CMS Releases Final Exchange Guidance for 2026 

    The Centers for Medicare and Medicaid Services (CMS) finalized 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 Notice for Benefit and Payment Parameters for 2026 (NBPP) and the 2026 Final Letter to Issuers on the Federally-facilitated Exchanges (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 final NBPP and Letter to assist states as you prepare for the 2026 certification process. As outlined below in bold, CMS is finalizing 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 updates related to standards for brokers and agents, Medical Loss Ratio standards, the Risk Adjustment Program, and the Basic Health Plan.  

    Standardized Plans 

    CMS finalized the requirement 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 finalized a slightly amended meaningful difference standard to the regulations. This standard would specifically apply to standardized plans since issuers 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, 
      • Prescription drug formularies, 
      • Or a combination of some or all these factors 

    CMS additionally finalized “minor updates” to the Federal standardized QHP plan options for plan year 2026 to ensure the plans continue to have actuarial values that fall within the allowed de minimis range for each metal level. In response to comments it received, CMS finalized the expanded bronze metal level designs at the 50% coinsurance rate used previously, rather than raising it to 60% as proposed. 

    Essential Community Provider (ECP) Review Process 

    CMS finalized its proposal to conduct Federal ECP certification reviews for QHPs in states that perform plan management functions beginning in plan year 2026. This policy change will permit the agency more consistent oversight over the QHP certification process, in addition to ensuring that issuers seeking certification include sufficiently robust provider networks. The ECP standards for the 2026 plan year will otherwise stay the same as for the 2024 plan year. 

    User fees and SADP cost-sharing limitations 

    CMS finalized its proposal 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 Exchanges on the Federal platform (SBE-FPs). In the event that Congress extends the enhanced premium tax credit (PTC) subsidies (authorized under the American Rescue Plan Act and Inflation Reduction Act) through the 2026 benefit year by the end of July 2025, which would support maintaining the current high Marketplace enrollment, CMS is finalizing an alternate FFE user fee rate of 2.2% and SBE-FP user fee rate of 1.8%, which are the lower of the initially proposed user fee rate ranges.  

    CMS also finalized its proposal to increase the SADP annual limitation on cost sharing by the 28.863 percentage point increase in the Consumer Price Index (CPI), which translates to $450 for one child and $900 for two children for the 2026 plan year. 

    Silver-loading  

    In acknowledgement of the comments it received regarding “silver or actuarial loading,” CMS is amending 156.80(d)(2)(i) to specify that issuers may adjust premium rates based on the actuarial value and cost-sharing design of the plan, or “CSR load,” so long as these practices are allowed by state regulators, are actuarially justified, and the issuer does not otherwise receive reimbursements for such amounts.  

     

    If your state has questions about any of the changes, please contact us at healthpolicynews@pcgus.com.  

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    Lisa Kaplan Howe (J.D.) is a Senior Advisor who has spent her career working in health law and policy. At PCG, she focuses on statutory and regulatory analysis and strategic advising, particularly related to health care policy. Lisa has provided subject matter expertise to support state health care reform efforts, including policy development and regulatory support for health insurance Marketplaces and state insurance plan management efforts, Medicaid expansion and Medicaid Waivers (including DSRIP Waivers) and State Innovation Waivers. Lisa led PCG’s work with the New Hampshire Insurance Department relative the state’s Section 1115 Medicaid Waiver to provide coverage to newly-eligible adults through the Marketplace and continues to support the states’ Marketplace plan management work. In those roles, Lisa has served as the chief advisor and policy expert related to Medicaid and private insurance law to the New Hampshire Insurance Department, helping to identify, analyze and lead strategic consideration of federal opportunities and requirements. Lisa is also part of the team helping to design Colorado’s Delivery System Reform Incentive Payment (DSRIP) program. Ms. Kaplan Howe also provides broad policy and regulatory support to PCG’s other health care clients across the country, analyzing policy and regulatory developments, providing strategic advice relative to regulatory questions, and drafting policy briefs and position papers. Lisa is a managing editor of PCG’s monthly health practice area newsletter, Health Policy News. Prior to joining PCG, Lisa served as Policy Director at New Hampshire Voices for Health, where she led legislative and regulatory analysis, strategic planning, and implementation of the organization’s policy agenda. Her work included drafting bills, amendments, testimony, and communications and testifying at hearings. Lisa also held the positions of Private Market Policy Manager and Consumer Health Policy Coordinator at Health Care for All of Massachusetts. While there, she managed private insurance market policy work and was a member of the organization’s internal health reform team. Lisa also practiced law in the Ropes & Gray health care department, advising health care provider and insurer clients.
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