The Centers for Medicare and Medicaid Services (CMS) has introduced a series of measures to tighten its oversight of health insurance exchange brokers, aiming to protect consumers and enhance accountability. Under the Notice of Benefit and Payment Parameters for 2026, CMS addresses concerns about broker misconduct while introducing broader changes to improve the functioning of health insurance exchanges.
Protecting Consumers: New Broker Oversight Measures
In response to reports of unethical practices, such as brokers switching consumers into different plans without their consent, CMS is implementing stricter controls. The new rule grants CMS the authority to immediately suspend agents or brokers under specific circumstances, including:
- Unacceptable Risks: Brokers or marketers may be barred if their actions jeopardize marketplace eligibility determinations, operations, or the security of marketplace IT systems.
- Updated Consent Forms: Brokers will now provide enhanced consent forms to ensure transparency and informed decision-making for consumers.
This crackdown follows reports by KFF Health News highlighting consumer complaints, underscoring the need for robust oversight to maintain trust in the system.
Enhancing Access to Subsidies and Tax Credits
The final rule also introduces provisions to help consumers retain tax credits for marketplace coverage, even when facing financial or administrative challenges:
- Premium Payment Grace Periods: Insurers must now adhere to one of two standards to prevent disenrollment for nonpayment:
- Keeping members who owe less than $10 in arrears.
- Retaining coverage for individuals who have paid at least 98% of their premiums.
- Tax Filing Notifications: Exchanges will notify enrollees who risk losing subsidies if they fail to file federal income taxes for two consecutive years, giving them a chance to correct the issue.
These measures aim to provide a safety net for consumers, particularly those at risk of losing coverage due to administrative oversights or minor payment discrepancies.
Risk Adjustment and Network Adequacy Updates
CMS is also refining its risk-adjustment system to better align with current claims data and improve auditing processes. These changes are designed to ensure insurers are compensated appropriately for covering high-risk populations, promoting fairness across the system.
Additionally, CMS is addressing network adequacy by requiring health insurance networks to include a sufficient number of Essential Community Providers (ECPs) to serve low-income and underserved populations. This provision ensures that vulnerable groups can access the care they need.
Key Provisions of the Final Rule
- Standardized Plans
- Insurers must ensure that standardized plans are meaningfully different from one another.
- Actuarial values for these plans must align with their designated metal tiers (bronze, silver, gold, platinum).
- User Fee Adjustments
- User fees for insurers will rise to 2.5% of premiums for federal exchanges and 2% for state exchanges using the federal enrollment platform.
- Annual Quality Updates
- Starting in 2026, CMS will introduce aggregated data reporting for quality updates, further enhancing transparency and performance monitoring.
Implications for Consumers and Insurers
For consumers, these changes signify stronger protections and greater clarity in navigating health insurance exchanges. The stricter oversight of brokers, combined with improved access to tax credits and subsidies, reduces the risk of losing coverage due to errors or misconduct.
For insurers, the new requirements around network adequacy, standardized plans, and risk adjustment ensure a more equitable and transparent marketplace. While the rise in user fees adds to operational costs, these changes are part of a broader effort to strengthen the exchange infrastructure and improve the consumer experience.
A Step Forward for Marketplace Stability
CMS’s final rule for 2026 represents a significant step in safeguarding consumer rights and enhancing the accountability of brokers and insurers. By addressing longstanding challenges such as broker misconduct and access to tax credits, the agency reaffirms its commitment to building a fairer and more reliable health insurance marketplace.
As these changes take effect, both consumers and insurers stand to benefit from a more robust, transparent, and equitable system. With continued monitoring and adjustments, CMS is poised to ensure the health insurance exchanges fulfill their mission of providing accessible and affordable coverage for all.
