ModifiedMedicarePolicy CMS-9884-F

Patient Protection and Affordable Care Act; Marketplace Integrity and Affordability (Final Rule)

Final rule revising Marketplace standards on enrollment, eligibility verification, agent/broker accountability, premium policies, and temporary program‑integrity measures affecting Federal Exchanges and related stakeholders.

Policy Summary

PayerMedicare

PolicyPatient Protection and Affordable Care Act; Marketplace Integrity and Affordability (Final Rule)

Policy CodePolicy CMS-9884-F

Change TypeMultiple additions, revisions, and temporary measures (sunset PY 2026)

Effective Date[INSERT DATE 60 DAYS AFTER PUBLICATION IN THE FEDERAL REGISTER]

Next Review Date

Key ActionExchanges on the Federal platform must reduce APTC so an auto‑re‑enrolled fully‑subsidized enrollee owes $5/month until they confirm or update eligibility for PY2026.

SourceLink

POLICY UPDATE CHANGES

Issuers may add past-due premium amounts from prior coverage to the initial premium required to effectuate new coverage and may deny effectuating new coverage if past-due and initial amounts are not paid in full, to the extent allowed by State law.

Revises definition of 'lawfully present' to exclude DACA recipients for purposes of Exchange and BHP eligibility for PTC, APTC, and CSR.

Establishes 'preponderance of the evidence' standard for HHS terminations for cause of agent, broker, and web-broker Exchange agreements.

Temporarily reinstates a 1-year failure-to-file-and-reconcile (FTR) ineligibility policy for APTC determinations for plan year 2026, with a sunset to revert to two-year policy in 2027.

Removes automatic 60-day extension to verify household income when there is an income inconsistency.

Temporary verification policies for income inconsistencies and pause of exception that accepted attestation without verification when IRS tax return data is unavailable for remainder of PY2025 and PY2026.

Temporary annual redetermination rule: if enrollee does not confirm and post-APTC premium is $0, Exchanges on the Federal platform must reduce APTC so enrollee owes $5/month.

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

90,863consumer complaints (unauthorized switches Jan–Aug 2024)

$26Bestimated improper enrollment cost (2024)

26,000+comments received on proposed rule

PY 2026temporary measures sunset

2 yearsAPT C discontinuation rule (post‑2026)

$5auto‑reenroll monthly obligation

Eligibility, Verification, and Enrollment Rules

inv-01: Eligibility, verification, and enrollment criteria

Temporary and permanent eligibility and verification criteria affecting APTC, CSR, annual redetermination, and FTR processes.

ALL of the following

For PY2026, Exchanges must determine a tax filer ineligible for APTC if HHS notifies the Exchange that the tax filer (or spouse) received APTC for a prior year and the tax filer or spouse did not file a Federal income tax return and reconcile APTC for that year; this 1-year FTR policy sunsets on December 31, 2026.
Exchanges must follow revised notice requirements for PY2026 FTR (amend §155.305(f)(4)); noticing procedures revert to the 2-year policy in PY2027.

ALL of the following

Removal of §155.315(f)(7): applicants will not receive an automatic 60-day extension beyond the statutory 90 days to resolve income inconsistencies; this change is effective as of the rule's effective date.
For remainder of PY2025 and through PY2026 Federal platform Exchanges must generate annual household income inconsistencies when an attested projected annual household income would qualify the taxpayer per 26 CFR 1.36B-2(b) but trusted data indicate projected household income is under 100% of the FPL; pause §155.320(c)(5) exception so Exchanges verify with other trusted data sources.

ALL of the following

When an enrollee does not submit an updated eligibility application by the last day to select a plan for Jan 1, 2026 and post-APTC premium would be $0, Exchanges on the Federal platform must reduce applied APTC so the enrollee owes $5 per month until they confirm/update eligibility; enrollees may reapply at any time to reinstate full APTC prospectively.

ALL of the following

HHS will apply a 'preponderance of the evidence' standard when terminating agents', brokers', and web-brokers' Exchange agreements for cause (definition and process added to §155.20 and §155.220(g)(2)).

ALL of the following

Exchanges and BHP agencies must verify applicant immigration status via DHS SAVE and are responsible for terminating coverage for DACA recipients upon the rule's effective date; DACA recipients are excluded from the regulatory definition of 'lawfully present' for purposes of QHP enrollment, PTC/APTC/CSRs, and BHP enrollment in electing States.

inv-02: Coverage and eligibility operational criteria

Coverage-related operational rules and temporary pauses affecting eligibility for APTC, SEPs, and EHB scope:

ALL of the following

For Federal platform Exchanges for PY2026 only, if an enrollee fails to submit an updated eligibility application by the plan-selection deadline for Jan 1, 2026 and would otherwise owe $0 after APTC, reduce applied APTC so enrollee owes $5/month until confirmation (FFEs and SBE-FPs must implement).

ALL of the following

Temporarily pause the monthly SEP for individuals eligible for APTC with projected household income at or below 150% FPL through PY2026 (finalized pause and conforming regulatory change).

ALL of the following

Require Exchanges to conduct pre-enrollment verification for at least 75% of new SEP enrollments through PY2026 (targeting misuse to obtain fully-subsidized plans).

ALL of the following

inv-03: Enrollment, payment, SEP, and issuer billing criteria

Extracted operational coverage and enrollment-related criteria and requirements included or finalized in these chunks.

ALL of the following

Exchanges must generally wait to discontinue APTC until a tax filer has failed to file and reconcile APTC for two consecutive years (the 2-year rule) except for the temporary 1-year FTR rule applicable for PY2026 which supersedes this for that year; notices for first- and second-year failures per Payment Notices are required.

ALL of the following

Issuers may adopt optional premium payment thresholds (net percentage-based threshold retained at minimum 95%); the finalized Payment Notice allows an optional fixed-dollar threshold up to $10 and gross percentage options (98% gross) as described in the Payment Notice context.

ALL of the following

Issuers, to the extent permitted by State law, may attribute a binder/initial premium payment for new coverage to past-due premium amounts owed for prior coverage and may refuse to effectuate new coverage unless past-due and initial premiums are paid in full; if adopted, such policy must be applied uniformly and consistent with nondiscrimination requirements and any state parameters.

inv-04: Past-due premium effectuation criteria

Coverage effectuation and claims payment rules when past-due premiums are paid or unpaid:

ALL of the following

If an individual pays past-due premiums for months during which they were covered, the issuer must pay any unpaid claims incurred during those months in accordance with the terms of coverage (including claims pended during grace period months).

ALL of the following

An issuer may refuse to effectuate new coverage unless the policyholder pays any past-due premiums owed for prior coverage and the initial premium (binder) for new coverage by the payment deadline, subject to State law and any issuer-adopted premium payment thresholds; this policy is optional for issuers and states may permit, limit, or prohibit it.

ALL of the following

Payments may be attributed to past-due premiums owed to the same issuer or an issuer in the same controlled group where State law permits; payments cannot be credited to past-due premiums owed to unrelated issuers.

inv-05: Past-due premium conditioning

Policy on conditioning new coverage on payment of past-due premiums:

ALL of the following

Issuers may, at their discretion and where permitted by State law, condition the effectuation of new coverage on payment of past-due premiums owed for prior coverage; States decide whether to allow issuers to apply this policy and may set additional parameters; issuers are not required to adopt the policy.

inv-06: DACA recipients and 'lawfully present' eligibility

Policy on Exchange eligibility related to immigration status:

ALL of the following

HHS finalizes a regulatory definition of 'lawfully present' that excludes DACA recipients for purposes of eligibility to enroll in a QHP through an Exchange and for PTC, APTC, CSRs, and for BHP enrollment in States that elect to operate a BHP; this change is applicable on the rule's effective date.

ALL of the following

Exchanges and BHP agencies must use DHS SAVE data matches to verify immigration status and are responsible for terminating coverage for DACA recipients currently enrolled upon the rule's effective date, with issuers required to send termination notices per §156.270(b)(1).

inv-07: Exclusion of DACA recipients from program eligibility

Stance and operational application regarding eligibility of DACA recipients under HHS programs.

ALL of the following

DACA recipients do not meet HHS' regulatory definition of 'lawfully present' for purposes of enrollment in a QHP through an Exchange, eligibility for PTC/APTC/CSRs, and enrollment in a BHP in electing States; Exchanges must verify status via SAVE and are responsible for terminating coverage for affected enrollees on the effective date.

inv-08: Eligibility exclusions and reenrollment rules

Coverage eligibility and reenrollment criteria finalized in this excerpt:

ALL of the following

DACA recipients are excluded from eligibility for QHP enrollment through an Exchange and for PTC/APTC/CSRs and BHP enrollment in electing States; Exchanges and BHP agencies must implement SAVE-based verification and terminate coverage for affected enrollees as of the effective date.

ALL of the following

For auto-reenrollment hierarchy, §155.335(j)(4) is removed to preserve consumer choice and prevent involuntary movement from bronze to silver plans; this change is effective PY2026 and beyond.

inv-09: Federal platform PY 2026 re‑enrollment criteria

Finalized stance for Exchanges on the Federal platform for PY 2026 regarding automatic re‑enrollment of fully‑subsidized enrollees:

ALL of the following

If an enrollee does not submit an updated eligibility application by the last day to select a plan for Jan 1, 2026 and would otherwise owe $0 after APTC, Exchanges on the Federal platform must reduce applied APTC such that the enrollee owes $5 per month until they confirm or update eligibility; enrollee may reapply at any time to reinstate full APTC prospectively.

ALL of the following

This $5 auto-reenrollment requirement applies only to Exchanges on the Federal platform for PY2026; State Exchanges are not required to implement for PY2026 and the requirement is limited in duration to PY2026 only.

ALL of the following

Exchanges must update notices and provide training to stakeholders to support implementation and consumer understanding of the $5 re-enrollment policy.

inv-10: Eligibility and re-enrollment criteria

Coverage-adjacent operational criteria finalized in this section:

ALL of the following

If an enrollee fails to submit an updated eligibility application by the plan-selection deadline for Jan 1, 2026 and APTC would fully subsidize premium ($0 enrollee share), Exchanges on the Federal platform must apply APTC such that the enrollee owes $5 monthly until they confirm or update eligibility; State Exchanges exempt.

ALL of the following

Removal of §155.335(j)(4) from the auto re-enrollment hierarchy is finalized to preserve consumer choice and prevent automatic movement from bronze to silver for CSR-eligible enrollees; States retain limited flexibility per §155.335(a)(2)(iii).

ALL of the following

The $5 monthly obligation is intended to incent active confirmation without causing undue hardship; CMS will provide notices, training, and technical assistance to stakeholders and enrollees.

inv-11: Auto re-enrollment and State Exchange options

Auto re-enrollment and State flexibility

ALL of the following

CMS finalizes removal of §155.335(j)(4) from the re-enrollment hierarchy to protect consumer choice and limit automatic plan changes that could create tax liabilities; effective PY2026 and beyond.

ALL of the following

State Exchanges may request Secretary-approved flexibility to apply alternative annual redetermination and re-enrollment procedures under §155.335(a)(2)(iii); HHS will review and provide technical assistance as part of annual plan submissions.

inv-12: FTR process: verification, data, and rationale

FTR verification and enforcement

ALL of the following

Finalizing a temporary 1-year FTR process for PY2026: Exchanges must determine an applicant ineligible for APTC after failing to file and reconcile APTC for 1 tax year for PY2026; this change sunsets Dec 31, 2026 and the 2-year FTR policy resumes in PY2027.

ALL of the following

Rationale: data from OEP indicates large numbers of potential reenrollments with FTR status and evidence of unauthorized enrollments; reverting to 1-year FTR for PY2026 is intended to reduce improper APTC payments and accumulated tax liabilities while temporary measures are in effect.

ALL of the following

Exchanges must implement FTR notice and recheck procedures (MOEN/OE notices, FTR Recheck notices, final EDN/Stop APTC) consistent with finalized rules; adequate notice and appeals information must be provided.

inv-13: Coverage and operational criteria

Final rule coverage-related operational criteria:

ANY of the following

For PY2026 only, Exchanges must apply the 1-year FTR rule and follow corresponding noticing requirements; after PY2026 the 2-year FTR rule resumes for PY2027 and beyond.
The automatic 60-day extension in §155.315(f)(7) is removed; applicants may still request case-by-case extensions under §155.315(f)(3).

ALL of the following

Notices related to FTR and income verification must include appeals information and guidance on resolving inconsistencies; Exchanges should follow the reinstated sequence of direct and indirect notices and FTR Recheck timing.

inv-14: Annual income DMI creation criteria

Criteria under which Exchanges on the Federal platform must create an annual income data-matching issue and pursue verification:

ALL of the following

Generate an annual income DMI when: (1) the consumer attests projected annual household income that would qualify the taxpayer per 26 CFR 1.36B-2(b) (historically framed as >=100% and <=400% FPL), (2) IRS/SSA/trusted data indicate household income is below 100% FPL, (3) the applicant is not determined eligible for Medicaid/CHIP, and (4) the attestation exceeds trusted data by a reasonable threshold (not less than 10% or an HHS-approved dollar amount).
Upon generation of an income DMI, Exchanges follow §155.315(f)(1)-(4) procedures: provide 90 days to resolve with temporary eligibility for financial assistance during that period; if unresolved, redetermine eligibility typically discontinuing APTC/CSR based on available tax data; policy sunsets end of PY2026.

ALL of the following

The reasonable discrepancy threshold must be at least 10% (may include dollar amount) and must be approved by HHS; non-citizen lawfully present persons ineligible for Medicaid by immigration status are excepted.

inv-15: Income DMI generation and resolution criteria

When an income DMI is generated and what happens:

ALL of the following

Income DMI triggers when IRS returns indicate annual household income below 100% FPL while the consumer attests projected income at or above 100% FPL (policy text revised to reference applicability per 26 CFR 1.36B-2(b) rather than explicit 400% upper bound).

ALL of the following

Once an income DMI is generated, the consumer has 90 days to submit documentation to resolve the inconsistency; temporary eligibility for APTC may be granted during this period but if unresolved, Exchanges will redetermine eligibility and may discontinue APTC/CSRs based on available tax data.

ALL of the following

This annual income DMI policy and related verification requirements are effective through PY2026 and will sunset thereafter; consumers may request extensions case-by-case per §155.315(f)(3).

inv-16: Income verification and premium payment threshold criteria

Criteria and operational stance for verifying projected annual household income when IRS tax data is unavailable and handling resulting DMIs:

ALL of the following

When IRS tax return data is unavailable, Exchanges must check other trusted income data sources to verify the applicant's attested annual household income; the prior exception accepting self-attestation (§155.320(c)(5)) is paused through PY2026 and Exchanges must follow the alternative verification process instead.

ALL of the following

If other trusted sources do not verify income, the Exchange issues an income DMI and grants 90 days of temporary eligibility for financial assistance during which the applicant should submit documentation to resolve the DMI; if unresolved after 90 days (and any granted extension), APTC may be reduced based on available tax data.

ALL of the following

These verification requirements and related temporary measures are finalized but will sunset at the end of PY2026, after which prior rules including §155.320(c)(5) will resume; Exchanges should provide guidance to consumers and issuers about the 90-day resolution process and acceptable documentation.

inv-17: Coverage integrity and enrollment timing rules

Policy stance regarding premium payment thresholds and enrollment timing affecting coverage termination risks and program integrity.

ALL of the following

Temporarily remove issuer access to fixed-dollar and gross-percentage premium payment thresholds on the Federal platform through December 31, 2026; issuers must use net percentage-based threshold (at least 95%) until the removal sunsets.

ALL of the following

CMS finalizes changes to OEP timing for benefit years starting Jan 1, 2027: OEP must begin no later than Nov 1 and end no later than Dec 31 with Exchanges on the Federal platform setting OEP as Nov 1–Dec 15 beginning PY2027; Exchanges should prepare operational and communications changes accordingly.

Regulatory References, Thresholds, and Code-like Values

Statutory references and benefit categoriesmixed

References to EHB categories and statutory bases; no specific billing codes present in this excerpt.

Premium payment threshold optionsmixed

$10	Finalized allowed fixed-dollar premium payment threshold for issuers to adopt (optional)

billing/coding applicabilitymixed

No explicit billing/coding codes provided in this section.

Regulatory references in this excerptmixed

45 CFR 155.20	Definition of 'lawfully present' and addition of 'preponderance of the evidence' definition.
45 CFR 155.220(g)	Termination for cause standards for agents, brokers, and web-brokers; evidentiary standard adoption.
45 CFR 155.335	Annual eligibility redetermination; new provisions for auto-reenrollment and $5 monthly requirement.

No billing or procedure codes in this sectionmixed

Regulatory cross-referencesmixed

§155.315(f)(1)-(4)	Procedures for creating and resolving income data-matching issues and extensions.
§155.315(f)(3)	State Exchange authority to extend verification period case-by-case.
§155.320(c)(3)(iii)	Income verification process when attested income differs from IRS/SSA data.

Premium threshold coding/policiesmixedCovered

net percentage-based threshold	Required premium payment threshold approach retained; issuers must use net percentage-based threshold (e.g., 95% of net premium or higher as applicable).
fixed-dollar threshold removed	Fixed-dollar ($10 de minimis) threshold flexibilities removed until PY 2027 (sunset end of PY 2026).
gross percentage threshold removed	Gross percentage-based threshold (e.g., 98% gross) removed until PY 2027 (sunset end of PY 2026).

De minimis AV thresholds

De minimis AV thresholds (general)+2 / -4 percentage points for most individual and small-group plans subject to AV requirements

De minimis AV threshold (expanded bronze)+5 / -4 percentage points for expanded bronze plans

Effective plan yearApplies beginning PY 2026 and beyond

Fixed-dollar premium threshold

Fixed-dollar premium threshold (issuer option)Issuers may adopt a fixed-dollar premium threshold amount of $10 or less (adjusted for inflation) as finalized in the 2026 Payment Notice

Issuer, Exchange, and Agent/Broker Responsibilities

Note

Issuer premium payment threshold flexibilities paused

Issuers will not have access to fixed-dollar or gross-percentage premium payment threshold flexibilities on the Federal platform through December 31, 2026. This suspension applies to the fixed-dollar and gross percentage-based premium payment threshold options finalized in prior guidance, but does not prohibit issuers from using the net-percentage threshold option where permitted. The pause is temporary and will sunset after PY 2026; thereafter, the Federal platform (FFE and SBE-FP) will, and State Exchanges may, offer issuers the previously finalized premium payment threshold flexibilities.

Effective through: December 31, 2026 (PY 2026).
Applicable platforms: Federally-facilitated Exchanges (FFE) and State-Based Exchanges on the Federal platform (SBE-FP).
Net-percentage threshold: Retained and available where applicable.

Billing Rule

Who can be required to pay past-due premiums

Key Terms and Definitions

Preponderance of the evidence

Preponderance of the evidence (evidentiary standard)HHS will apply a 'preponderance of the evidence' standard of proof for termination-for-cause decisions regarding agents', brokers', and web-brokers' Exchange agreements under §155.220(g); definition added at §155.20

PurposeAdopted to improve transparency and accountability in enforcement actions against agents, brokers, and web-brokers

Procedural protectionsAgents, brokers, and web-brokers retain notice, rebuttal, and reconsideration rights (including timelines referenced in the rule) when subject to enforcement

Lawfully present (as revised)

Lawfully present (revised) — DACA exclusionRegulatory definition of 'lawfully present' at §155.20 is revised to exclude DACA recipients for purposes of Exchange and BHP eligibility for PTC, APTC, and CSRs; effective upon the rule's effective date

Policy Summary

PayerMedicare

PolicyPatient Protection and Affordable Care Act; Marketplace Integrity and Affordability (Final Rule)

Policy CodePolicy CMS-9884-F

Change TypeMultiple additions, revisions, and temporary measures (sunset PY 2026)

Effective Date[INSERT DATE 60 DAYS AFTER PUBLICATION IN THE FEDERAL REGISTER]

Next Review Date

Key ActionExchanges on the Federal platform must reduce APTC so an auto‑re‑enrolled fully‑subsidized enrollee owes $5/month until they confirm or update eligibility for PY2026.

SourceLink

On This Page

Amend §156.115(d) to prohibit coverage of specified sex-trait modification procedures as an EHB beginning PY2026 and add a definition at §156.400 (effective PY2026 and beyond).

ALL of the following

For individuals who lose Medicaid coverage, the SEP was lengthened to 90 days (Payment Notice revisions); Exchanges align certain SEP effective dates across Exchanges.

ALL of the following

If past-due premiums for months during which the individual was covered are paid, the issuer must pay unpaid claims incurred during those months (including claims pended during grace period months per §156.270(d)(1)).

ALL of the following

Issuers and Exchanges are expected to resolve cases where non-payment resulted from issuer/Exchange error expeditiously so consumers are not improperly charged past-due premiums; rescission-triggered terminations do not create past-due premiums for post-termination periods.

Optional adoptionUse of the fixed-dollar threshold is optional for issuers and may be subject to State law and issuer policies

Binder payment exclusionThe fixed-dollar threshold may not be applied to the binder payment (initial premium) when effectuating coverage

Gross premium percentage threshold

Gross premium percentage threshold (issuer option)Issuers may adopt a gross premium percentage threshold of 98% or more of the gross premium (including APTC) as an option per the 2026 Payment Notice

Temporary removal through PY 2026Use of gross percentage-based thresholds is paused on the Federal platform through December 31, 2026 (sunset)

Optional adoption after PY 2026After the sunset, FFEs/SBE-FPs will, and State Exchanges may, allow issuers to implement this option per Payment Notice guidance

Net premium percentage threshold

Net premium percentage threshold (required approach)Net percentage-based premium threshold must be at least 95% of the net premium after APTC (retained in final rule)

Applicability during temporary periodIssuers on the Federal platform must rely on the net percentage-based threshold while fixed-dollar and gross thresholds are paused through PY 2026

Issuer discretion thereafterFFEs/SBE-FPs will, and State Exchanges may, permit issuers to offer other threshold flexibilities after the sunset date

Issuer premium payment threshold (45 CFR 155.400(g))

Issuer premium payment threshold authority (45 CFR 155.400(g))Issuers may refuse to effectuate new coverage subject to any premium payment threshold the issuer has adopted pursuant to 45 CFR 155.400(g).

State law limitationApplication of issuer thresholds is subject to applicable State law and any State-determined parameters

Uniformity and nondiscriminationIf an issuer adopts a past-due premium policy or thresholds, it must apply the policy uniformly and consistent with nondiscrimination requirements

Auto-reenrollment monthly enrollee obligation

Auto-reenrollment monthly enrollee obligationExchanges on the Federal platform must reduce APTC so that an auto-reenrolled fully-subsidized enrollee owes $5 per month until they confirm eligibility for PY 2026

Implementation timingFFEs and SBE-FPs implement for benefit year 2026; State Exchanges implementation timing differs (States begin in 2027 per final rule modifications)

Enrollee right to reinstate full APTCEnrollees can submit an application at any time to confirm eligibility and prospectively reinstate full APTC

Enrollee monthly premium owed after APTC for auto re‑enrolled fully‑subsidized enrollees

Monthly premium owed after APTC for auto re‑enrolled fully‑subsidized enrolleesThe remaining monthly enrollee obligation is $5 after Exchanges reduce applied APTC for auto re-enrolled fully-subsidized enrollees (Federal platform, PY 2026)

Effect on issuers with net-thresholdsIf an issuer has a net percentage-based threshold, an enrollee with a $5 billed obligation may be required to pay the issuer's applicable threshold amount (e.g., $4.75 under a 95% threshold) to avoid grace period placement

Prospective reinstatementFull APTC may be reinstated prospectively once enrollee confirms eligibility via application update

Nominal monthly premium

Nominal monthly premium used for auto re-enrollment policyThe rule sets a nominal monthly premium of $5 for automatically re-enrolled fully-subsidized enrollees on the Federal platform for PY 2026

PurposeIntended to incentivize enrollees to confirm/update eligibility while minimizing hardship from higher required payments

Reversion/temporary naturePolicy finalized for PY 2026 on Federal platform; State Exchanges have flexibility and broader timing differences

FPL filing / eligibility reference

FPL filing/eligibility reference (examples)Examples in the preamble reference thresholds around $14,580–$14,600 for 2024 filing and APTC eligibility illustrations

Context of examplesUsed to illustrate filing thresholds and scenarios where income attestation and IRS data comparisons generate DMIs

Not an absolute eligibility cutoffFinal rule replaces some explicit percent-of-FPL framing with references to applicability per 26 CFR 1.36B-2(b)

Reasonable discrepancy threshold

Reasonable discrepancy threshold for income DMIsA reasonable threshold must not be less than 10%; it may include a dollar amount and must be approved by HHS

Exchange discretionExchanges may establish reasonable thresholds higher than 10% as appropriate, subject to HHS approval

ApplicabilityUsed when attested projected income exceeds trusted data by the threshold to trigger an annual income DMI on the Federal platform through PY 2026

Income applicability threshold

Income applicability threshold for generating income DMIIncome DMI is generated where an enrollee's attested projected annual household income would qualify the taxpayer per 26 CFR 1.36B-2(b) and trusted data (IRS/SSA) indicate income below applicable thresholds

Replacement of explicit FPL capRule removes the prior explicit 400% FPL reference and ties applicability to the IRS rule (26 CFR 1.36B-2(b))

Temporary applicationThis annual income DMI generation approach is finalized through PY 2026, after which prior verification treatment reverts unless further action is taken

Income verification minimum threshold

Income verification minimum thresholdA minimum 10% percentage difference between attested projected income and trusted data is required to trigger an income DMI (Exchanges may adopt higher thresholds)

Includes optional dollar amountThreshold may include a dollar amount in addition to the percentage criterion

Applied during temporary periodPolicy and threshold application for annual income DMIs on the Federal platform are in effect through PY 2026 (sunset at end of 2026)

Net percentage-based premium threshold requirement

Net percentage-based premium threshold requirementNet percentage-based premium threshold must be at least 95% of the net premium after APTC (retained in the final rule)

Temporary constraint on other thresholdsFixed-dollar and gross-percentage threshold flexibilities are removed on the Federal platform through PY 2026, leaving the net-percentage approach in place

Post-sunset flexibilityAfter Dec 31, 2026, FFEs/SBE-FPs will, and State Exchanges may, permit issuers to use other threshold flexibilities per Payment Notice guidance

Temporary removal timeframe

Temporary removal timeframe for fixed-dollar & gross thresholdsFixed-dollar and gross percentage-based premium payment threshold flexibilities are removed through the completion of PY 2026 (sunset December 31, 2026)

Reason for temporary removalTemporary measure to address urgent program integrity concerns tied to improper and unauthorized enrollments in fully-subsidized plans

Post-sunset reviewPolicy will be re-evaluated with potential reintroduction of flexibilities after PY 2026 per Payment Notice and agency analysis

OEP end date (December 15 vs January 15)

OEP end date considerationRule discusses changing the Open Enrollment Period end date from January 15 to December 15 for future benefit years (analysis proposed for PY 2027 and beyond)

Potential operational impactsIssuers and Exchanges should prepare for schedule changes affecting billing cycles, consumer communications, and plan selection timing

Implementation timing in final ruleCMS indicates intent to set Federal platform OEP as Nov 1–Dec 15 starting PY 2027, subject to Payment Notice and subsequent guidance

Only the person contractually responsible for payment — the policyholder — may be required to pay past-due premiums under this policy. For individual-market policies, the policyholder is the named policyholder on the contract (for child-only coverage typically a parent or legal guardian). For individual market family policies, the policyholder is not a dependent. For group coverage, the policyholder is typically the employer or union. Issuers may not condition effectuation of new coverage on payment of past-due premiums by any individual other than the policyholder. An issuer may, to the extent permitted by State law, attribute a binder/initial premium payment for new coverage to past-due premium amounts owed to that issuer or to another issuer in the same controlled group; issuers may not credit payments toward premiums owed to an unrelated issuer.

Child-only policy: policyholder is the parent or legal guardian.
Family individual-market policy: policyholder is the named policyholder (not a covered dependent).
Group market: policyholder is typically the employer or union.
Issuer may only attribute payments to past-due premiums owed to the same issuer or another issuer in the same controlled group.

Prior Authorization

Annual redetermination auto-reenrollment action required by Exchanges

For Exchanges on the Federal platform (FFEs and SBE-FPs) during the PY 2026 annual redetermination process, when an enrollee would have a $0 monthly premium after application of APTC and does not submit an application for an updated eligibility determination by the deadline to select a plan for January 1, 2026 coverage, the Exchange must reduce the APTC applied to the policy so that the enrollee owes $5 per month. This $5 monthly obligation applies for the first month and every month thereafter until the enrollee confirms or updates their eligibility and plan selection. Enrollees automatically re-enrolled with a $5 monthly premium after APTC retain the ability to submit an application at any time to confirm eligibility and reinstate the full APTC prospectively.

Applies when enrollee's portion of premium would otherwise be $0 after APTC.
Trigger: Failure to submit updated eligibility determination by the plan-selection deadline for January 1, 2026 coverage.
Obligation: Enrollee owes $5 monthly until confirmation/update.
Restoration: Enrollee may confirm at any time to reinstate full APTC prospectively.

Documentation Required

Exchange responsibilities for FTR and income verification

Exchanges have responsibilities for Failure to File and Reconcile (FTR) processes and for income verification operations. Exchanges must: issue required FTR and FTR Recheck notices in the prescribed sequence and timing; generate income documentary matching items (DMIs) when attested projected household income and trusted data sources diverge by an Exchange-established reasonable threshold (not less than 10 percent, which may include a dollar component); act as the intermediary to collect documentary evidence from applicants; coordinate rechecks with IRS/SSA data; and, when applicable, terminate coverage for individuals found ineligible (for example, certain DACA recipients) consistent with applicable verification results and timelines. Exchanges must also provide notice of appeal and extension rights in FTR processes and follow the specified recheck timelines and temporary eligibility protections while applicants resolve inconsistencies.

Notices: MOEN/OE with FTR language, FTR Recheck notices, final EDN/Stop APTC as specified.
Income DMIs: Create when attested income ≥100% and ≤400% FPL and trusted data indicate income <100% FPL and discrepancy exceeds Exchange-approved threshold (≥10%).
Documentation: Exchanges collect documentary evidence from applicants and facilitate resolution with IRS/SSA.
Temporary eligibility: Maintain temporary coverage during DMI resolution period and allow extensions where appropriate.
FTR enforcement: Exchanges must provide information on appeals and how to contact Marketplace Appeals Center.

Note

Operational actions for Exchanges and intermediaries

Operationally, Exchanges, agents, brokers, EDE partners, and issuers must prepare to implement the foregoing verification and auto-reenrollment requirements. Specific operational actions include generating annual income DMIs where attested income and trusted data conflict, sending the full sequence of FTR and DMI notices within required timeframes, collecting and processing documentary evidence from applicants, coordinating rechecks with IRS/SSA, and ensuring temporary eligibility and appeal processes are available. Exchanges on the Federal platform are expected to implement these processes by the specified effective dates and to provide technical assistance and communications to issuers, intermediaries, and consumers. Agents, brokers, and web-brokers assisting with enrollments must obtain and document consumer consent before making application or enrollment updates, and Exchanges may suspend intermediary access where unacceptable risks to accuracy or operations are identified.

Exchanges to notify issuers of DMI and FTR processes and timelines.
Intermediaries must document consumer consent for application or enrollment updates (per §155.220).
EDE partners and issuers should be prepared to assist enrollees in gathering documentation to resolve DMIs.
HHS to provide technical assistance and educational materials to State Exchanges not on the Federal platform.
HHS may suspend agent/broker/enroller privileges when unacceptable risks to accuracy, operations, applicants, or enrollees are identified.

Billing Rule

Reminders on past-due premium effectuation and claims payment

Issuers and Exchanges should preserve transparency and consumer protections when applying past-due premium policies. Issuers that choose to condition effectuation of new coverage on payment of past-due premiums must apply such policies uniformly and in a nondiscriminatory manner, and should work with agents and brokers to ensure consumers understand payment requirements and consequences of non-payment. If past-due premiums are remitted for months during which the individual was covered, the issuer must pay any unpaid claims incurred during those months.

Uniform application: Issuers must apply past-due premium policies uniformly to similarly situated applicants.
Claims payment: If past-due premiums for covered months are paid, issuers must pay unpaid claims for those months.
State law: Issuers' ability to implement these policies remains subject to applicable State law and State exchange capabilities.

RationaleHHS interprets the ACA statutory scheme as not conferring eligibility for insurance affordability programs to DACA recipients

Operational actionExchanges and BHP agencies must verify immigration status via DHS SAVE and terminate coverage where applicable per finalized rule provisions

Expanded bronze plans

Expanded bronze plans — definitionExpanded bronze plans are bronze plans that cover and pay for at least one major service (other than preventive services) before the deductible or meet HDHP requirements per IRC section 223(c)(2)

Regulatory referenceReferenced in §156.140(c) and discussed in de minimis AV threshold context for PY 2026

AV threshold implicationExpanded bronze plans have a distinct de minimis AV range (+5 / -4) compared with other plans

Specified sex-trait modification procedure

Specified sex-trait modification procedureDefined at §156.400 in this rule; such procedures will not be covered as an EHB beginning PY 2026

Effective yearProhibition on coverage as EHB effective for PY 2026 and beyond

Definition addedDefinition added to the regulations to implement the EHB exclusion

Premium adjustment percentage

Premium adjustment percentageRegulatory methodology re-adopted to set premium growth measures and used for cost-sharing and required contribution percentage calculations starting PY 2026

UsesApplied to annual limits on cost sharing, required contribution percentages, and related parameters under §155.605(d)(2)

BasisRe-adopts the premium growth measure used for PY 2020–PY 2021 and applies it beginning PY 2026

Grace period

Grace period referenceGrace period rules (three consecutive months) govern termination and claims pendings; relevant to claims payment when past-due premiums are remitted

Claims consequenceIssuers must pay unpaid claims for months when past-due premiums are remitted for months the individual was covered, including pended claims during grace period months

Interaction with effectuation policyIndividuals in a grace period may owe up to 3 months of premium net of APTC when attempting to effectuate new coverage

Past-due premiums

Past-due premiums — definition'Past-due premiums' are premiums due but not paid for periods during which the individual was covered (for example, during a grace period); after coverage termination, no premium is due

Who can be required to payThe policyholder (person contractually responsible for payment) is the party who may be required to pay past-due premiums; dependents/employees cannot be compelled to pay as policyholders

State discretionStates may permit, limit, or prohibit issuers from adopting past-due premium policies and may determine controlled-group applicability