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2027 Draft Letter to Issuers in the Federally-facilitated Exchanges
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Operational and technical guidance for issuers seeking to offer qualified health plans (QHPs), including stand-alone dental plans (SADPs), in Federally-facilitated Exchanges (FFEs), FF-SHOPs, and applicable State-based Exchanges on the Federal Platform for the 2027 plan year; affects issuers and State regulators interacting with the FFE process.
Proposes discontinuing the federal requirement for issuers to offer standardized plan options and discontinuing federal standardized plan option differential display requirements on HealthCare.gov and DE pathways beginning for the 2027 plan year.
Proposes discontinuing non-standardized plan option limits and exceptions at 45 CFR 156.202 effective for the 2027 plan year.
Auto re-enrollment rules updated: Exchanges must auto re-enroll enrollees into QHPs with the most similar network when their current QHP is unavailable, and Exchanges must re-enroll catastrophic enrollees as permitted by State law; CSR auto-reenroll option from 2024 Payment Notice was removed by the 2025 rule.
Network adequacy review proposal: States may elect to conduct provider access reviews if they demonstrate authority and technical capacity; otherwise CMS will conduct Federal network adequacy reviews including time/distance and wait-time standards.
CMS proposes to allow non-network plans to obtain QHP certification if they demonstrate sufficient access to a broad range of providers, including ECPs, and to rescind the requirement that all plans must use a provider network.
CMS proposes to reduce the minimum ECP threshold requirement from 35% to 20% for the overall threshold, FQHC threshold, and family planning threshold for plan year 2027 and thereafter.
QHP issuers must report Patient Access API usage metrics and prior authorization metrics beginning with plan year 2025 data, reported by March 31, 2026 as part of the 2027 QHP certification process.
Beginning January 1, 2026, responses to providers denying a prior authorization request (excluding drug requests) must include a specific reason for denial.
Transparency in Coverage reporting will include new and modified elements for 2027, such as breakdowns of claims by behavioral health status and new questions about pre-service benefit requests and plan-level reasons for out-of-network denials.
Certification, Enrollment, and Coverage Standards
QHP certification criteria and operational rules
Covered when ALL of the following operational and submission requirements are met for issuers applying for QHP certification in FFEs:
See Plan Validation Workspace guidance.
Apply the submission path appropriate to the State's role.
Follow the Plan Year timeline for allowed change windows.
Legal entity information in HIOS must match executed documents.
Corrected final QHP data may be required during a limited correction window after final submission.
Coordinate with State plan management when applicable.
Refer to Plan Withdrawal FAQs on qhpcertification.cms.gov.
Coordinate SERFF transfers with HIOS deadlines per State guidance.
Follow 45 CFR 144.103 and uniform modification rules at §147.106 when assessing plan identity.
See comment submission instructions in the Draft Letter.
Auto Re-enrollment and Crosswalk Criteria
Auto re-enrollment and Plan ID crosswalk rules that determine how enrollees are reassigned when their current QHP is unavailable:
Crosswalk data facilitate enrollment transactions for enrollees who do not actively select a different QHP.
The crosswalk hierarchy governs selection order when multiple candidate plans exist.
Ensure alternative plans comply with applicable eligibility and product rules.
Issuers may voluntarily continue standardized options but those plans would not be visually distinguished on HealthCare.gov under the proposal.
Refer to the FF-SHOP guidance in the Draft Letter.
Non-network plan and ECP certification criteria (proposed)
Proposed conditions for certifying non-network QHPs and related ECP expectations (applicants must satisfy ALL applicable attestations and thresholds):
Attestations are submitted in the Plans and Benefits section of MPMS.
Public posting must be easily accessible and understandable to enrollees, potential enrollees, and providers.
The proposed reduction is from 35% to 20% for these thresholds beginning in plan year 2027.
Narrative justifications would be replaced by structured contract offer/status fields in MPMS.
Time/distance and telehealth approaches remain consistent with prior guidance.
Follow the Plan Year timeline for permitted service area edits.
See Appointment Wait Time Secret Shopper Survey Technical Guidance.
ECP crediting, State review option, and interoperability reporting criteria
Rules for how ECP contract negotiation statuses count toward certification and State review options (crediting and reporting):
Record executed contracts in MPMS to receive full credit.
Use the specified contract negotiation status values when recording provider outreach outcomes.
Documentation may be requested by CMS during compliance reviews after final submission.
States must submit attestations before the QHP certification cycle to assume review duties.
See Section 156.221(f) and 156.223(c) for reporting obligations and templates/examples.
This requirement applies regardless of communication method used to convey the denial to providers.
Issuer reporting and communication requirements
Issuer reporting and public communication obligations that must be satisfied as part of certification and ongoing transparency:
Section 156.221(f) specifies the Patient Access API metrics to report.
Section 156.223(c) requires public reporting of prior authorization metrics.
This is required regardless of communication method and supports provider transparency.
CMS may use these data for compliance purposes in future plan years.
Apply statutory indexing and rounding rules when determining limits.
Issuers and agents/brokers should monitor final rulemaking for obligations.
SBC, notices, and consumer support criteria
Requirements and guidance for SBCs, notices, translated materials, and AI/AN cost-sharing representation:
Use updated translated materials from the Departments' guidance when preparing notices and SBCs.
Include the required note box below coverage examples: 'Note: These numbers assume the patient received care from an IHCP provider or with IHCP referral at a non-IHCP...'
Sample completed SBCs provide instructive examples for limited cost-sharing and zero cost-sharing plans.
Continue to follow existing appeals and tribal guidance documents.
Operational Codes, Systems, and Reporting Identifiers
| HIOS | Health Insurance Oversight System product and plan IDs required for all issuers |
| MPMS | Marketplace Plan Management System module of HIOS for QHP submissions (where applicable) |
| SERFF | NAIC System for Electronic Rate and Form Filing for States performing plan management functions |
| 45 CFR 155.20 | Definition of 'standardized options' proposed for removal |
| 45 CFR 156.201 | Requirements pertaining to standardized plan options proposed for removal |
| 45 CFR 156.202 | Non-standardized plan option limits and exceptions proposed for removal |
| Network Adequacy Template and ECP selection/status entries are submitted via MPMS; no CPT/HCPCS/ICD codes specified in this section. |
| No codes listed |
| No codes listed |
Issuer and Broker Operational Requirements (What You Must Do)
Execute and Submit QHP Certification Agreement & Senior Officer Acknowledgement
Issuers must sign and submit a QHP Certification Agreement and a Senior Officer Acknowledgement to CMS after finalizing plan data; CMS will sign and return the Agreement with the final list of certified QHPs, after which issuers may market plans as certified. Failure to meet the Plan Year 2027 QHP Data Submission and Certification Timeline deadlines or to submit accurate and complete applications after the issuer change deadline may result in denial of certification.
Use Limited Data Correction Window — risk of enforcement if inaccurate
Issuers may be required to resubmit corrected QHP data during a limited data correction window after the final submission deadline; making corrections in that window without CMS or State approval or remaining inaccurate after the final deadline may subject issuers to compliance actions including decertification and suppression from HealthCare.gov.
Request Reconsideration within 7 Calendar Days with Supporting Documentation
An issuer denied QHP certification may submit a written request for reconsideration to HHS within 7 calendar days of the denial notice and must include all supporting documentation; overturning an HHS denial requires clear and convincing evidence that the plan met the general certification criteria.
Report ECP selections, contract statuses, and attestations in MPMS; provide public benefit-amount URL
QHP issuers must report ECP selections and contract negotiation/status information in MPMS for ECPs they include or have offered contracts to, and non-network plans must attest to provider availability, public posting of benefit amounts, exceptions processes, and provide public URLs and outreach/customer assistance documentation.
- Select ECPs from the Final Plan Year ECP List in the MPMS ECP UI and append the applicable facility status for each selected ECP.
- Non-network plans must provide a publicly accessible URL showing plan benefit amounts and attest to exception and customer assistance processes.
Record MPMS Contract Negotiation Statuses and apply crediting rules for ECP calculations
Record one of the enumerated contract negotiation statuses for each relevant ECP in MPMS (e.g., contract executed; contract offer made, awaiting response; pre-contract negotiations; offer rejected; no response after outreach; facility closed; exclusivity prohibits contracting; not licensed/certified; relocated out of service area; incorrect categories). Certain statuses count toward certification calculations: executed contracts count for threshold/category/Indian health care calculations, and 'contract offer made, awaiting response' or 'offer rejected' also receive credit for the ECP category per county and Indian health care calculations.
- Designate 'contract executed' to receive credit toward ECP threshold, category-per-county, and Indian health care calculations.
- Designate 'contract offer made, awaiting response' or 'offer rejected' to receive credit for ECP category-per-county and Indian health care provider calculations.
- Document and continue outreach efforts (calls/emails/letters, varied times/days) if other statuses prevent meeting ECP elements; be prepared to provide outreach documentation if requested.
Provide Specific Reason for Non-Drug Prior Authorization Denials (effective Jan 1, 2026)
Beginning January 1, 2026, when a QHP issuer denies a prior authorization request (excluding drug coverage requests), the response to the provider must include a specific reason for the denial, and issuers must report prior authorization metrics publicly as required.
- Ensure provider communications for non-drug prior authorization denials include a specific reason for denial.
- Prepare to publicly report prior authorization metrics for the 2025 plan year by March 31, 2026 as part of the certification reporting requirements.
Submit Marketing Materials on Request and Retain Responsibility for Downstream Content
Agents, brokers, and web-brokers would be required to submit marketing materials to CMS upon request during an investigation and remain responsible for marketing content posted by downstream entities they work with; the proposed expansion lists seven specific prohibited marketing practices that may be enforced if finalized.
- Be prepared to provide marketing materials to CMS upon request during an investigation.
- Maintain oversight of downstream affiliates and remove or correct prohibited or misleading marketing content per proposed §155.220(j)(3).
Key Terms and Acronyms
Context, Rationale, and Operational Notes
This chapter summarizes the QHP certification process that applies to issuers seeking certification in Federally-facilitated Exchanges (FFEs) for the 2027 plan year. It relies on statutory and regulatory authority under the ACA and implementing regulations and applies to issuers operating in States where CMS performs plan management functions as well as States performing plan management and making recommendations to CMS. Issuers must submit a complete QHP application by the initial submission deadline in the Plan Year 2027 timeline and resolve validation issues before final submission; CMS will review submissions, notify issuers of corrections, and may require corrected final QHP data during a limited data correction window after the final deadline.
Issuers must use the designated submission systems for FFEs (for example, MPMS/HIOS) and follow the plan withdrawal and certification procedures described by CMS. An issuer’s final plan confirmation is generally the last opportunity to withdraw a plan from certification consideration. Failure to meet certification requirements, deadlines, or to submit accurate and complete applications can result in denial of certification or other enforcement actions.
The proposed 2027 changes would remove federal requirements that have governed standardized plan options and the federal limits on non-standardized plan options. Specifically, the proposal would eliminate the definition and regulatory requirements for standardized options at 45 CFR 155.20 and 45 CFR 156.201, and would remove the non‑standardized plan option limits at 45 CFR 156.202 effective for the 2027 plan year.
Operationally, CMS explains that discontinuing these federal requirements would not force issuers to stop offering existing standardized or non‑standardized plans; issuers may voluntarily continue or change offerings. If an issuer discontinues a plan that results in affected enrollees, auto re‑enrollment will follow the crosswalk hierarchy at §155.335(j), and other plan‑management processes (for example, plan ID continuity and HIOS rules) continue to govern how plan changes are handled during certification.
CMS strengthened oversight of agent and broker activity by updating the Agent and Broker FFE Registration Termination List (RTL) in July 2025 to include two‑character reason codes that identify registered or terminated status and specify the enforcement reason. These codes are intended to increase transparency for issuers and State Departments of Insurance about enforcement actions.
The proposed 2027 Payment Notice would also expand the definition of prohibited marketing practices for agents, brokers, and web‑brokers by specifying seven particular practices (for example, offering inducements, misusing government logos, or misstating deadlines) and would require these intermediaries to submit marketing materials to CMS upon request during investigations. These proposals aim to reduce misleading or coercive advertising and to clarify agent/broker responsibilities for downstream content.
CMS is aligning interoperability and prior authorization reporting with the QHP certification timeline so that Patient Access API usage metrics and prior authorization metrics for the 2025 plan year are collected as part of the 2027 QHP certification process. Under the Interoperability and Prior Authorization final rule, issuers must report aggregated, de‑identified Patient Access API usage metrics and publicly report prior authorization metrics by March 31, 2026 for 2025 plan year data; CMS intends to collect these data via new MPMS questions in the QHP application.
Additionally, beginning January 1, 2026, issuer responses to provider denials of prior authorization requests (excluding drug requests) must include a specific reason for the denial. The QHP certification submission will include MPMS questions that ask issuers to attest to publishing prior authorization metrics and to whether they provide a specific reason for denials in provider communications, aligning reporting and provider communication expectations with certification checks.
Document Changes and Effective Dates
Proposed discontinuation of federal standardized plan option requirements and differential display on HealthCare.gov becomes effective for the 2027 plan year.
Proposed removal of non-standardized plan option limits at 45 CFR 156.202 effective for the 2027 plan year.
Proposed reduction of minimum ECP threshold requirements from 35% to 20% for overall, FQHC, and family planning calculations beginning with the 2027 plan year.
Issuers must report 2025 Patient Access API usage metrics and prior authorization metrics as part of the 2027 QHP certification process by March 31, 2026.
Issuers must include a specific reason in provider communications for prior authorization denials (excluding drug requests) beginning January 1, 2026.
Transparency in Coverage reporting for the 2027 plan year will include new and modified elements (e.g., behavioral health breakout, pre-service benefit processing questions, plan-level reasons for out-of-network denials) and submission via MPMS/HIOS as specified.
SADP annual limitation on cost sharing updated for 2027 to $450 for one child and $900 for two or more children after CPI adjustments and rounding rules.
Agent and Broker Registration Termination List (RTL) updated in July 2025 to add two-character reason codes to improve transparency of enforcement actions.
Proposed expansion of prohibited marketing practices for agents, brokers, and web-brokers described in the 2027 Payment Notice (7 specified practices) and a proposal to require marketing materials submission upon request.
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