CMS Finalizes Improvements to Marketplace Plan Selection with 2026 Final Rule

The Department of Health and Human Services (HHS) finalized the 2026 Final Rule for Affordable Care Act coverage on January 13, 2025. This Final Rule puts into action the protections previously proposed in the 2026 Proposed Marketplace Rule with a few slight modifications.

The Centers for Medicare & Medicaid Services (CMS) aim to increase protections for individuals enrolling in marketplace plans, accessibility to affordable health care options, and their authority to suspend agents who make changes to enrollees’ coverage without their permission.

As of the organization’s latest update, 24 million individuals have selected an Affordable Care Act (ACA) insurance plan during the 2025 Open Enrollment Period (OEP); let’s evaluate the final rules that could possibly affect how agents, consumers, and carriers interact with the marketplace.

More Rigorous Agent Reviews & Penalties for Unauthorized Actions

CMS will now be able to use their expanded authority to immediately suspend an agent or broker’s account if they “pose an unacceptable risk to the accuracy of marketplace eligibility determinations, operations, applicants, or enrollees.” The new penalties will reduce the number of complaints of unauthorized activity in the marketplace. Updating this policy advises agents to maintain compliance or be terminated immediately.

Standardized Actuarial Values for Qualified Health Plans

To improve plan quality and choice, CMS is standardizing actuarial values for all plans that meet the Qualified Health Plan requirements. This will guarantee that Qualified Health Plans in one area are equitable to the plans offered in another area. This ensures that individuals in urban areas and rural areas have the same access to quality and affordable ACA coverage.

Additionally, the 2026 Final Rule requires that standardized plans have actuarial values aligned with the plans’ metal levels to maintain consistency in plan designs between carriers. Carriers that offer multiple standardized plans within the same product network type, metal tier, and service area must differentiate the plans between one another to limit duplicate plans.

Educate yourself on your client’s plan benefits, network, and drug coverage to better inform them on their own plan benefits. We also encourage you to become familiar with popular marketplace plans in your area to help your client select the right plan for them.

Updated Consumer Authorization and Consent Form

A revised model consent form, CMS’ document intended for agents to use while collecting client authorization and eligibility applications, was finalized with the 2026 Final Rule. The most updated version meets the standard requirements that were outlined in 2024, but serves as a guide for agents. There is also a template agents can use while making a phone call to collect the required information before processing an application.

Ritter has a consumer authorization form and call script and a consumer eligibility attestation script and accompanying form. Download these scripts for free to maintain marketplace compliance!

Allowable Cost-Sharing Reduction Loading

Previously, CMS proposed cost-sharing reduction loading practices are allowed when the adjustments are reasonable, justified, and follow state law. CMS finalized that cost-sharing reduction “loading is allowed when the adjustments are actuarially justified and follow state law, provided the [plan] issuer does not receive reimbursements for such amounts.”

“Cost-sharing reduction loading” refers to when carriers increase premiums to offset the costs associated with offering health insurance tax credits. Enrollees use premium tax credits to minimize the amount they pay for deductibles, copayments, and coinsurance. Cost-sharing loading can inflate the costs of a health plan, but the increased costs don’t always reflect an increase in value of benefits.

Updating Payment Threshold to Minimize Coverage Gaps

CMS is giving carriers the ability to set one of three thresholds to reduce coverage gaps for marketplace clients. These protections empower clients that may be experiencing financial hardship.

Three payment caps have been finalized by CMS:

Source: Centers for Medicare & Medicaid Services, “HHS Notice of Benefit and Payment Parameters for 2026 Final Rule.”

Historically, clients with lower incomes may have been placed into a grace period when they fail to pay their monthly premium, forcing them to make a full premium payment by the end of the month. These grace periods often result in termination, causing individuals to lose health care coverage for carrying a balance.

ACA Subsidy Clients Granted Two Years to File

Finally, individuals who receive subsidies and fail to reconcile their tax credits for two consecutive years must be notified that they could lose their premium tax credits. CMS now requires that the proper exchange must make individuals aware of their standing and provide the opportunity for them to reconcile their subsidies. Ensure that your clients are aware that they must reconcile their premium tax credits when filing their federal taxes.

The changes and client protections CMS finalized for the 2026 plan year have a clear goal: enhance consumer protections while ensuring access to quality and affordable coverage. Become familiar with this Final Rule and educate yourself on the marketplace plans available in your area.

For recommendations of products and plans to add to your portfolio, you can view Ritter’s ACA plan offerings, or contact your sales specialist to arrange a time to discuss carriers that would be beneficial for your business. Become a Ritter agent (if you’re not already) to have a team of professionals on your side.