Final Rule: PPACA; Marketplace Integrity and Affordability, 45 CFR Parts 147, 155, and 156, 90 Fed. Reg. 27074 (June 25, 2025)
HHS has released final regulations addressing rules to ensure the integrity of the Affordable Care Act (ACA) Exchanges (also known as Marketplaces) and the affordability of health coverage, including changes to annual cost-sharing limits, eligibility and enrollment procedures, and the definition of essential health benefits. Here are highlights:
- Revised 2026 Annual Cost-Sharing Limit. HHS has updated the methodology for calculating the “premium adjustment percentage” (which is used to set several ACA parameters) to align with premium trends, beginning in 2026. Based on this change, the maximum annual limitation on cost-sharing for 2026 has been revised to $10,600 for self-only coverage and $21,200 for other than self-only coverage. The revised limitation supersedes the previously announced 2026 limit of $10,150 and $20,300.
- Eligibility and Enrollment. Several of the Exchange integrity revisions are designed to “tamp down on improper enrollments and the improper flow of federal funds” that HHS believes resulted from the temporary expansion of ACA premium subsidies in response to Covid-19, including, for instance, revised standards for Exchange income verification processes, new rules for pre-enrollment verification for special enrollment periods, and modified eligibility redetermination procedures. These provisions will apply for the 2026 plan year but are currently scheduled to sunset at the end of that year. The regulations also remove Deferred Action for Childhood Arrivals (DACA) recipients from the definition of “lawfully present” for eligibility and enrollment in Exchanges, effective August 24, 2025. Starting in 2027, the Exchange annual open enrollment period has been revised to begin no later than November 1 and end no later than December 31 of the calendar year preceding the benefit year, with the period not to exceed 9 weeks. (The federal Exchange open enrollment period will run from November 1 through December 15.) Coverage for enrollments during the open enrollment period must begin on January 1.
- Essential Health Benefits. Beginning with the 2026 plan year, insurers subject to the essential health benefits (EHB) requirement (i.e., non-grandfathered individual and small group market plans) may not cover “specified sex-trait modification procedures” as an EHB. A lengthy definition of specified sex-trait modification procedures has been added to the final version of the regulations. HHS explains that insurers may still voluntarily cover specified sex-trait modification procedures and states are generally not prohibited from mandating coverage of such services, but they are not considered EHB.
EBIA Comment: Although most of these regulations are primarily of interest to insurers and Exchange operators, employer plan sponsors and their advisors should particularly be aware of the revised annual cost-sharing limits. In addition, changes to eligibility and enrollment procedures may limit some employees’ access to Exchange coverage, indirectly impacting enrollment in employer-sponsored health plans. For more information, see EBIA’s Health Care Reform manual at Sections XXI.A (“Establishment and Functions of Exchanges”), XXI.B (“Exchange Eligibility”), XXI.C (“Qualified Health Plans (QHPs) and Essential Health Benefits”), and XXI.G (“Premium Tax Credits”). See also EBIA’s Self-Insured Health Plans manual at Section XV.D (“Designing Cost-Sharing Features”).
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