The new federal rule introduces stronger broker oversight, stricter eligibility verification, and updated risk adjustment models — with significant implications for health insurers and providers.
WASHINGTON, May 15, 2026 – The U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), has issued a sweeping final rule governing health insurance standards for 2027, introducing significant changes to ACA Marketplace operations, broker conduct, and insurer flexibility.
What the Rule Covers
The 2027 Payment Notice final rule sets standards for Health Insurance Exchanges, as well as for health insurance issuers, agents, brokers, and web-brokers who connect millions of consumers to Affordable Care Act coverage. It also establishes updated user fee rates for issuers offering qualified health plans through Federally-facilitated Exchanges and State-based Exchanges on the Federal platform. CMS
Stricter Broker and Agent Oversight
One of the most significant provisions targets broker conduct on the Exchanges. CMS is finalizing a requirement that agents, brokers, and web brokers use an HHS-approved standardized form to meet eligibility application review and consumer consent documentation requirements, effective for plan-year enrollments beginning January 1, 2028.
The rule also bans misleading marketing tactics, including false “$0 premium” claims, and will no longer allow NPN to add or change on the Healthcare.gov system.
Tighter Eligibility and Subsidy Verification
CMS is tightening income and eligibility verification checks on subsidy eligibility, including stricter verification for low-income applicants and failure-to-file or reconcile tax cases. The rule also implements provisions of the Working Families Tax Cut legislation, including changes that limit premium tax credit eligibility for certain lawfully present immigrants with incomes below 100% of the federal poverty level.
Risk Adjustment Model Updates
To keep HHS risk adjustment models current while promoting model stability, CMS is finalizing a recalibration of the HHS risk adjustment models for the 2027 benefit year, using 2021, 2022, and 2023 benefit-year enrollee-level data. Kaufmanhall
Insurer and State Flexibilities
The rule removes the requirement for standardized ACA plans, lifts limits on non-standardized plans, and allows new types of non-network Qualified Health Plans beginning in 2028. States also gain more control over provider networks and Essential Community Provider reviews for exchange plans. Notably, CMS retained the existing requirement for insurers to contract with at least 35% of Essential Community Providers, rejecting a proposed reduction to 20%.
What This Means for Healthcare Organizations
The final rule represents a meaningful shift in how ACA Marketplace plans are administered, sold, and verified. For healthcare providers and billing professionals, tighter eligibility verification and stricter broker documentation standards will require updated workflows for patient enrollment and insurance confirmation, areas where revenue cycle accuracy is critical.
Organizations that proactively align their operations with the new standards will be better positioned to avoid claim denials and compliance risks as the 2027 plan year approaches.