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.
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