Patient Protection and Affordable Care Act, HHS Notice of Benefit and Payment Parameters for 2027; and Basic Health Program

HHS finalized the Notice of Benefit and Payment Parameters for 2027, establishing payment parameters for the HHS-operated risk adjustment and risk adjustment data validation (HHS-RADV) programs. The rule sets 2027 user fee rates for issuers offering qualified health plans (QHPs) through Federally-facilitated Exchanges (FFEs) and State-based Exchanges on the Federal platform (SBE-FPs). The rule also implements certain provisions of the Working Families Tax Cut (WFTC) legislation.

The final rule establishes civil money penalties (CMPs) for noncompliant issuers and other responsible entities, and sets standards governing agents, brokers, and web-brokers. It expands and codifies hardship exemption eligibility and implements the State Exchange Improper Payment Measurement (SEIPM) program.

On QHP certification, the rule finalizes provider access standards and essential community provider standards, addresses certification of non-network plans, and prohibits issuers from including routine non-pediatric dental services as an Essential Health Benefit (EHB). The rule also establishes requirements related to defrayal for the cost of any State-required benefits in addition to the EHB.

The rule finalizes cost-sharing flexibilities for catastrophic and individual market bronze plans and establishes catastrophic plans with plan terms of up to 10 consecutive plan years. It also addresses QHP issuer quality improvement strategies (QISs) and revises which enrollees are included in Federal Basic Health Program (BHP) payment calculations to States.