HHS Sets 2027 Health Plan Rules and Penalties
Published Date: 5/20/2026
Rule
Summary
Starting in 2027, health insurance plans on federal and state marketplaces will see new rules to make coverage fairer and easier to use. These changes affect insurance companies, agents, and people buying plans, including new fees, penalties, and better protections for those with hardships. Expect updates on plan quality, dental coverage limits, and longer-term catastrophic plans, all aiming to keep your health coverage solid and affordable.
Analyzed Economic Effects
11 provisions identified: 6 benefits, 3 costs, 2 mixed.
End of APTC Repayment Limits
For taxable years beginning after December 31, 2025, APTC repayment limits are eliminated: if your advance premium tax credit (APTC) exceeds the premium tax credit (PTC) you qualify for, you must increase your tax liability by the amount of that excess. This changes how repayment is handled when APTC and final PTC differ.
No Routine Adult Dental as EHB
Starting with these 2027 parameters, issuers are prohibited from counting routine non-pediatric (adult) dental services as an Essential Health Benefit (EHB). This means marketplace plans cannot designate routine adult dental as part of the EHB package when certifying QHPs.
Expanded Hardship Exemption Rules
The rule expands and codifies eligibility for hardship exemptions related to Marketplace coverage and enrollment, affecting who may qualify for hardship-based exemptions and related enrollment options starting with the 2027 parameters. These changes are finalized in this rulemaking and take effect under the rule.
Cost-Sharing Flexibility for Bronze & Catastrophic
The rule finalizes cost-sharing flexibilities for catastrophic and individual-market bronze plans under the 2027 parameters. If you enroll in a bronze or catastrophic plan on the Marketplace, these flexibilities may change how deductibles and out-of-pocket costs apply.
No PTC for Income-Based SEP Enrollments
Effective January 1, 2026, a plan enrolled through a special enrollment period (SEP) that is based only on your expected income relative to the Federal Poverty Level (an "income-based SEP") is not considered a qualified health plan (QHP), so no premium tax credit (PTC) is allowed for that coverage. If you enroll using an income-based SEP, you may not be eligible for PTC assistance.
HDHP Definition Includes Bronze/Catastrophic
Effective for months beginning after December 31, 2025, the definition of a high-deductible health plan (HDHP) is amended to include bronze and catastrophic individual coverage sold through an Exchange. This may affect whether certain Exchange plans meet HDHP criteria.
Basic Health Program Payment Calculation Changes
The rule includes revisions affecting which enrollees are included in Federal Basic Health Program (BHP) payment calculations to States. This changes how Federal payments to States operating a BHP are calculated under the 2027 parameters.
Multi-Year Catastrophic Plans (Up to 10 Years)
The rule establishes catastrophic plan options that may have plan terms of up to 10 consecutive plan years under the 2027 parameters. If you enroll in a catastrophic plan, you may be able to keep the same plan terms across multiple years.
Stricter Agent/Broker Standards and Enforcement
The rule finalizes standards for agents, brokers, and web-brokers, including documentation and consent requirements and authority for HHS to suspend an agent's or broker's ability to transact with the Exchange until incidents or noncompliance are remedied. These standards apply to entities assisting Exchange consumers.
Provider Access & QHP Non-Network Certification
The rule finalizes provider access standards, essential community provider standards, and requirements for QHP certification of non-network plans for the 2027 parameters. If you buy a Marketplace plan, these standards affect network adequacy and whether non-network plans can be certified as QHPs.
Defrayal for State-Required Benefits
The rule finalizes requirements related to payments (defrayal) for the cost of any State-required benefits that are in addition to the Essential Health Benefits (EHB). In States that require additional benefits, payments must be made either to the enrollee or to the issuer on the enrollee's behalf to defray those costs.
Your PRIA Score
Personalized for You
How does this regulation affect your finances?
Sign up for a PRIA Policy Scan to see your personalized alignment score for this federal register document and every other regulation we track. We analyze your financial profile against policy provisions to show you exactly what matters to your wallet.
Key Dates
Department and Agencies
Related Federal Register Documents
2026-12069 — Medicare Program; Strengthening Oversight of Accrediting Organizations (AOs) and Preventing AO Conflicts of Interest, and Related Provisions
This new rule makes sure the groups that check Medicare providers play fair and follow clear rules to avoid conflicts of interest. It updates how psychiatric hospitals are reviewed and tightens rules for providers who lost their Medicare status but want back in. These changes affect Medicare providers and accrediting groups, start June 16, 2027, and aim to keep care safe and trustworthy.
2026-10890 — Medicare Program; Alternative Payment Model Updates and the Increasing Organ Transplant Access (IOTA) Model
Starting July 1, 2026, Medicare is updating the Increasing Organ Transplant Access (IOTA) Model to help kidney transplant hospitals do even better at getting more people transplanted and improving care quality. These changes affect hospitals involved in kidney transplants and aim to make the process smoother and more effective, with new payment rules that reward success. This update is part of a 6-year plan running through 2031 to save more lives and boost patient experience.
2026-10292 — Medicaid Program; Medicaid Managed Care State Directed Payments and Medicaid Fee-for-Service Targeted Medicaid Practitioner Payments
This proposed rule changes how states can pay Medicaid managed care plans and certain doctors to make sure payments are fair, efficient, and encourage enough providers to offer quality care. It affects states, Medicaid managed care organizations, and targeted Medicaid practitioners, aiming to keep payments balanced and services available. Comments on these changes are open until July 21, 2026, so stakeholders have time to weigh in before it’s finalized.
2026-07205 — Medicare and Medicaid Programs; Patient Protection and Affordable Care Act; Interoperability Standards and Prior Authorization for Drugs for Medicare Advantage Organizations, Medicaid Managed Care Plans, State Medicaid Agencies, Children's Health Insurance Program (CHIP) Agencies and CHIP Managed Care Entities, and Issuers of Qualified Health Plans on the Federally-Facilitated Exchanges
This new rule will help Medicare, Medicaid, CHIP, and health plan companies share patient info more easily and speed up drug approval requests. It affects Medicare Advantage, Medicaid, CHIP, and health plans on federal exchanges, aiming to make care smoother and faster. These changes will start soon and could save time and money by cutting red tape.
2026-04797 — Medicare and Medicaid Programs; CY 2026 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; and Medicare Prescription Drug Inflation Rebate Program; Correction
This document fixes some typos and technical mistakes in the Medicare and Medicaid payment rules for 2026. It affects doctors, healthcare providers, and anyone using Medicare Part B by clarifying payment policies and program requirements starting January 1, 2026. These corrections help make sure payments and coverage rules are clear and accurate, so everyone gets paid right and on time.
2026-04467 — Patient Protection and Affordable Care Act, HHS Notice of Benefit and Payment Parameters for 2027; and Basic Health Program; Correction
This correction fixes some missing labels in important tables from the 2027 health insurance rules under the Affordable Care Act. It mainly affects insurance companies and people using marketplace plans by clarifying how risk and payments are calculated. These fixes take effect right away on March 6, 2026, ensuring everyone has clear info before the 2027 plan year starts.
Previous / Next Documents
Previous: 2026-10045 — Endangered and Threatened Wildlife and Plants; Reclassification of the Rough Popcornflower From Endangered to Threatened With a Section 4(d) Rule
Great news! The rough popcornflower, a rare plant, is no longer in immediate danger of extinction, so it’s being moved from endangered to threatened status starting June 18, 2026. The U.S. Fish and Wildlife Service is also putting new rules in place to help protect and conserve this plant as it continues to recover. This change helps focus efforts while keeping the plant safe for the future.
Next: 2026-10060 — Safety Zone; Straits of Mackinac, Lake Michigan, MI
From June 1 to July 31, 2026, the Coast Guard is setting up a temporary safety zone around two vessels doing underwater surveys in the Straits of Mackinac, Lake Michigan. Boats can’t enter within 500 yards of these vessels during the day unless they get special permission. This keeps everyone safe while important pipeline inspections happen, with no extra costs for the public.