Uncertainty Looms over the 2026 Plan Year 

As carriers, Insurance Departments and Exchanges across the country prepare for the 2026 plan year, there is an unprecedented amount of uncertainty, starting with a dispute over recently regulatory changes.  Health and Human Services (HHS) finalized a Marketplace Integrity and Affordability Rule on June 25, 2025. The policy changes related to open enrollment and special enrollment periods, the impact of missed premium payments, subsidy eligibility and amounts, Essential Health Benefits and QHP actuarial value, and coverage of Deferred Action for Childhood Arrivals (DACA) recipients. Following the rule, a group of cities and health care and small business organizations challenged several provisions in the case of City of Columbus v. Kennedy, resulting in delayed enforcement of the following provisions: 

• A $5 monthly premium for individuals in fully-subsidized plans that do not apply for updated eligibility determinations. 

• Allowing QHP carriers to deny coverage for individuals who previously failed to pay premiums. 

• Allowing Exchanges to deny eligibility for advance payment tax credits (APTCs) for individuals that fail to file taxes. 

• Imposing additional eligibility verification requirements. 

• Expanding de minimis actuarial value (AV) ranges for QHP plan levels. 

While the case remains pending, these changes will be on hold for the time being and, as a result of the stay on the changes AV levels, in particular, QHP carriers across the nation are preparing to refile QHPs that had taken advantage of the expansion of de minimis value ranges. CMS recently provided guidance outlining a new expedited timeline for carriers to refile plans.  

The impact of this uncertainty will expand beyond carriers and state regulators. Last-minute changes will impact the window shopping opportunities that typically precede the Exchange open enrollment period. Even Section 1332 Waiver states are impacted as they await final plan rates to allow them to file for their 2026 Pass-through Funding. 

At the same time, there is a renewed effort to continue the expanded APTCs that began under the American Rescue Plan Act (ARPA), were renewed under the Inflation Reduction Act (IRA), but will expire at the end of the year without further action. While any hope of extension seemed unlikely, there is a renewed effort to extend them through the legislation to avoid the government shutdown. The lack of certain action to date, provides more uncertainty in the market, impacting premiums and purchasing decisions. This too impacts Section 1332 Waiver states who’s funding is tied to the extend of APTCs. 

While policy uncertainty remains at the federal level, an increasing number of states are considering the opportunities they have to affect policy reform. See PCG’s recent fact sheet for more information.