2027 ACA Final Rule Makes Strides to Reduce Premiums

On May 15, the Centers for Medicare & Medicaid Services (CMS) released the Notice of Benefit and Payment Parameters for 2027. Or, the 2027 ACA final rule.

There are several notable changes for agents selling Affordable Care Act (ACA) plans in the federal and state marketplaces.

Here are the most notable updates for agents selling marketplace products!

Finalized Changes in the Individual Marketplace

Overall, the ACA final rule increases pressure for compliance, tightens enrollment verification requirements, and increases options for clients.

Tighter Compliance and Marketing Guidelines

The new compliance standards prohibit agents from:

• Offering cash or rebate incentives to increase enrollments
• Promising $0 premiums without proper qualification
• Misrepresenting deadlines or eligibility requirements

Additionally, agents are required to use CMS’ standard consumer consent form and eligibility review form beginning in PY2028.

We suggest agents document everything, including client consent, and avoid misleading marketing tactics. Acting in your clients’ best interests is your duty as their trusted advisor!

Stricter Eligibility Verification

The marketplace is making strides to verify consumers’ eligibility for ACA plans. These changes will reduce fraud for the Under-65 market.

• Prior to enrollment, marketplaces will be required to verify 75 percent of Special Enrollment Period (SEP) enrollments
• In cases of clients whose incomes fall under 100 percent of the Federal Poverty Line (FPL), additional income verification will exist
• Marketplaces are no longer able to rely on self-attested income when IRS income data is available

Please note that these updates may increase enrollment processing times, increase the number of documents you’ll need to collect from clients, and you may encounter enrollment rejections if an application is not complete.

Removal of the 150 Percent FPL SEP

Agents, be prepared to prove qualifying life events rigorously since CMS is discontinuing the 150 percent SEP after 2026. Beginning in 2027, there will be fewer clients who can enroll in marketplace coverage outside of the Open Enrollment Period (OEP).

What to expect:

• Fewer year-round enrollment opportunities outside of the OEP
• More reliance on the OEP and qualifying life events
• Greater scrutiny of SEP enrollments
• Additional documentation required for SEP enrollments

Make sure you’re educating your local community about the changes ahead of the OEP and how they can access affordable healthcare through SEPs when they qualify.

New Tax Credit and Subsidy Restrictions

Eligible noncitizens will have limited access to Advanced Premium Tax Credits or Cost-Sharing Reductions. Those lawfully present who have incomes below 100 percent of the FPL are ineligible for Medicaid and no longer qualify for subsidies.

Advise your immigrant clients of these new requirements; fact-find and search for affordable options, even though there may be fewer options available.

Tightening the Failure to File and Reconcile Rule

Individuals will not be able to receive subsidies if they fail to file or reconcile their tax credits for the prior year.

Be prepared to assist your clients report the subsidies they received on their tax return. We have a helpful breakdown in our post on the subject.

Plan Design Changes and Landscape Shifts

CMS is also finalizing several policies that may cause changes to marketplace products and overall, aim to reduce premium costs for eligible clients.

Key Product Updates

Agents selling marketplace plans may notice more non-standardized plan options. Note, to receive subsidies, clients must be enrolled in a Qualifying Health Plan (QHP). Additionally, there have been more updates to QHPs.

The 2027 ACA final rule also introduces non-network QHP plans. These are open access style plans that increase flexibility and provide additional benefits.

Please note that this can complicate plan comparisons. With non-standardized plan benefits allowed in these non-network QHP plans, individuals may find it more confusing to compare plans one-to-one.

Differentiate yourself as an advisor in the market! Understand all marketplace products offered in your area and be able to assist clients with comparisons or find the right product for them.

Growth of Catastrophic Plans

For clients who struggle to afford bronze-level premiums and who don’t need health services often, a catastrophic plan could be a budget-friendly safety net. Think about your younger clients or individuals who don’t qualify for subsidies based on their income.

More individuals will be eligible for catastrophic coverage with the expanded hardship exemptions in the final rule.

Catastrophic plans can now last up to 10 years and include pre-deductible value-based services.

Lower User Fees

Additionally, user fees have been lowered in the final rule. For the federal exchange, user fees are 1.9 percent. For state-based marketplaces on the federal platform, user fees will be 1.5 percent.

In the long term, this may reduce premiums. Please note that costs may vary more in state marketplaces.

Additionally, states gain control over provider networks and certification requirements.

Stricter Improper Enrollment Prevention Measures

To protect consumers, CMS eliminates the flexible premium payment thresholds.

Also, agents may encounter more audits and marketplace accountability. There will be less tolerance for errors.

We recommend that agents always act in their clients’ best interests and act compliantly to avoid scrutiny and additional auditing from CMS.

Removing Third Party Certification Vendor Authorization

Annual certification and re-certification will now be facilitated through CMS’ MLMS platform. New and returning agents will access their annual marketplace training through this platform only.

What Does This Mean for Agents?

The 2027 final rule will change how you sell marketplace plans and service your ACA clients.

• Expect more documentation and slower enrollments
• SEP business will be harder to secure and will require additional documentation
• Compliance is critical for agents selling in the individual marketplace
• Plan options will expand, but become more complex to compare
• Your role is increasingly more important as a trusted advisor

Overall, the 2027 ACA final rule is about control and accountability for agents and marketplaces. We’ll start to see more government oversight, stricter verification processes, and less room for error.

Your success will be determined by your ability to advocate for your clients compliantly, operate efficiently with proper documentation, and offer client support from an advisor’s perspective.

Register with Ritter to gain support from our Under-65 Sales team that can help you navigate changing requirements. You’ll also receive access to tools such as IntegrityCONNECT to help you house important client enrollment information and documents.