HHS finalizes 2027 payment rule

The U.S. Department of Health and Human Services issued its 2027 Notice of Benefit and Payment Parameters final rule on May 15, setting the next round of standards for Affordable Care Act exchanges, insurers, agents, brokers and web-brokers. CMS said the rule also revises federal Basic Health Program payment calculations to states, alongside changes to exchange user fees, marketing rules and plan design standards. The agency described the package as the 2027 Payment Notice final rule and said it applies to plan-year 2027 exchange operations. ### Which programs does this rule actually cover? The May 15 CMS fact sheet says the rule governs Health Insurance Exchanges, qualified health plan issuers, and the agents, brokers and web-brokers that connect consumers to ACA coverage. CMS also said the rule includes provisions tied to the HHS-operated risk adjustment and risk adjustment data validation programs, 2027 user fee rates for issuers on federally facilitated exchanges and state-based exchanges on the federal platform, and federal Basic Health Program payment calculations. (cms.gov) The February 11 proposed rule shows the same package was framed around ACA implementation, exchange payment parameters and Basic Health Program policy, with comments due by March 13. That timeline places the May 15 action as the final step in this year’s rulemaking cycle for the 2027 notice. (cms.gov) ### What changed for insurers and exchange plan design? CMS said the final rule removes the requirement that qualified health plan issuers using HealthCare.gov offer standardized plan options and also removes limits on the number of non-standardized plan options issuers can offer. The agency said it is also creating a certification pathway for some non-network plans to qualify as exchange plans. (federalregister.gov) The CMS fact sheet also says the rule bars issuers from treating routine non-pediatric dental services as an essential health benefit, adds cost-sharing flexibility for catastrophic and individual-market bronze plans, and allows catastrophic plans with terms of up to 10 consecutive plan years. CMS said the rule expands and codifies hardship exemption eligibility as well. (cms.gov) ### Why are people focused on the Basic Health Program language? CMS said the final rule includes “revisions affecting which enrollees are included in Federal Basic Health Program payment calculations to states.” That language matters because Basic Health Program funding formulas help determine how states are paid for coverage offered outside the exchange structure to eligible low-income residents. (cms.gov) The May 15 materials do not, in the portions publicly summarized by CMS, spell out a broader business conclusion about insurer incentives. What they do establish is that enrollee treatment in the federal payment calculation is being revised for 2027, and that the Basic Health Program was important enough to be included in the formal title of both the proposed and final rules. (cms.gov) ### What did CMS say about fraud, marketing and eligibility checks? CMS said the rule strengthens oversight of agents, brokers and web-brokers by clarifying prohibited marketing practices and standardizing documentation supporting consumer consent and eligibility review. The agency’s fact sheet lists examples of prohibited conduct, including cash or cash-equivalent inducements, false claims that consumers will always qualify for zero-dollar coverage, and misleading statements about enrollment deadlines. (cms.gov) CMS Administrator Dr. Mehmet Oz said in the agency’s press release that “American taxpayers deserve to know their dollars are going only to people who truly qualify.” The press release said the rule reinstates pre-enrollment verification for special enrollment periods, requires added income documentation in some cases, and aligns advance premium tax credit eligibility with the Working Families Tax Cut legislation. (cms.gov) ### Does this rule affect Medicare and Medicaid broadly? The CMS materials tied to this action describe it as an ACA exchange and Basic Health Program rule, not a broad Medicare payment rule. Medicare has its own separate 2027 final rulemaking tracks, including an April 2, 2026 final rule for Medicare Advantage and Part D, according to CMS. (cms.gov) The Basic Health Program sits alongside Medicaid-related coverage pathways for low-income residents in some states, but the May 15 payment notice itself is framed by CMS around ACA exchange operations, insurer standards and federal exchange administration for plan year 2027. The May 15 CMS fact sheet says the 2027 Payment Notice final rule is now issued, and the agency linked the final text in a PDF posted with the release. (cms.gov) The next practical step is implementation by exchanges, issuers, agents, brokers and participating states ahead of the 2027 plan year.