CMS has finalized a broad set of changes to the ACA marketplace that will affect how insurers design plans, how eligibility is verified, and who qualifies for federal subsidies.
The final rule, published May 15, arrives as total ACA enrollment has declined 5% to 23.1 million in 2026 following the expiration of enhanced premium tax credits at the end of 2025. The remaining risk pool has grown older and sicker, with the share of enrollees in bronze plans jumping from 30% to 40% as healthier consumers either left the market or enrolled in cheaper coverage. Multiple major insurers have also pulled back or exited the market entirely.
Six notes:
1. CMS is eliminating the requirement that insurers on the federal exchange offer standardized plan options, along with the cap on how many non-standardized plans they can offer. Under the prior framework, payers were limited to two non-standardized plan designs per metal level. Insurers can now keep, modify or drop existing standardized offerings.
Effective in plan year 2028, a new pathway will allow non-network plans to obtain certification as qualified plans on the federal exchange. These plans set fixed benefit amounts rather than relying on contracted provider networks, allowing enrollees to seek care from any provider. To qualify, payers must show that a sufficient range of providers accepts the plan’s benefit amount as full payment, including essential community providers and mental health and substance use disorder specialists.
The rule also allows catastrophic plans to span up to 10 consecutive years and expands hardship exemption eligibility so more lower-income individuals can access catastrophic coverage when their income changes.
2. CMS is reinstating pre-enrollment verification requirements for special enrollment periods that were originally finalized in June 2025 but blocked by a federal court. Under the final rule, exchanges on the federal platform must verify eligibility before enrollment for at least 75% of new SEP enrollments, covering a broader set of categories beyond just loss of coverage. The rule also makes permanent two income verification requirements that were included in the earlier 2025 rule but were also blocked.
3. The rule bans insurers from counting routine adult dental services as an essential health benefit, reversing a policy from the Biden administration. CMS said the change better reflects what a typical employer plan covers, which is the ACA’s statutory benchmark.
Beginning in 2028, states that mandate benefits beyond the federal essential health benefits floor must cover the costs of those added benefits for exchange enrollees themselves, rather than those costs flowing through to consumers or federal subsidies.
4. The final rule aligns several provisions with H.R. 1. Starting in 2027, tax credit eligibility will be narrowed to citizens and a limited set of lawful immigrants, excluding refugees, asylum recipients, and others with lawful status. The rule continues a ban on the low-income special enrollment period for households at 150% of the FPL, extending the ban beyond 2026.
5. Agents, brokers, and web-brokers will be required to use a standardized form for eligibility application review and consumer consent documentation, effective in 2028. CMS also codified a list of banned marketing practices, including providing cash or cash equivalents to induce enrollment, falsely claiming consumers will qualify for zero-dollar premiums, and misrepresenting enrollment timelines.
6. The user fee for plans on the federally facilitated exchange will drop to 1.9% of monthly premiums in 2027, down from 2.5% in 2026. The fee for state-based exchanges on the federal platform falls to 1.5%, down from 2%. CMS said the reductions should help put downward pressure on premiums. The risk adjustment user fee is also being reduced, to $0.18 per member per month.
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