This overview is excerpted from Manatt on Health, Manatt’s subscription service that provides in-depth insights and analysis focused on the legal, policy and market developments. For more information on how to subscribe and to activate a complimentary one week trial to Manatt on Health, please reach out to Barret Jefferds.
On October 4, the Centers for Medicare & Medicaid Services (CMS) released the proposed Notice of Benefit and Payment Parameters (NBPP) for plan year 2026. This proposal begins the annual rulemaking cycle for the Marketplaces and federal regulation of group and individual health insurance coverage, no doubt accelerated with the aim of finalizing the rule before Inauguration Day.
With the notable exceptions of the focus on alleged broker fraud and a new proposal to change how HIV pre-exposure prophylaxis (PrEP) is addressed in the risk adjustment program, this year’s notice focuses on clean-up of issues addressed in previous Marketplace payment rules. The proposed rule would:
- Crack down on alleged broker misconduct by codifying rules to monitor and investigate suspected fraud and suspend brokers’ participation in Marketplace enrollment;
- Update risk adjustment to phase out market pricing adjustment for hepatitis C and create new rating factor for HIV PrEP;
- Permit qualified health plan issuers not to terminate coverage of enrollees that have failed to pay a small portion of their premium;
- Make state-based Marketplace (SBM) enrollment data and audits public; and
- Raise user fees for issuers in states using the federal Marketplace platform, with the assumption of enrollment decline due to the expiration of the enhanced premium tax credits and a contingency plan if the enhanced credits are extended.
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