On May 15, the Department of Health and Human Services (HHS) published the Notice of Benefit and Payment Parameters for 2027, which sets standards for the health insurance marketplaces. The final rule includes provisions on essential community providers (ECPs), catastrophic plans, and non-network health plans. It also implements several provisions from the Working Families Tax Cut legislation (WFTCL).
HHS is not finalizing the proposal to decrease the minimum percentage of ECPs required to be in-network for qualified health plans from 35% to 20%, which includes inpatient hospitals. The rule will maintain the 35% ECP threshold along with separate 35% thresholds for federally qualified health centers and family planning providers. However, the rule allows states to use the federal marketplace to conduct their own ECP certification reviews.
The rule expands the catastrophic plan term to either one year or multiple consecutive years not to exceed 10 years. Catastrophic plans with terms of at least two years may use value-based insurance designs to offer preventive services without requiring the beneficiary to satisfy their deductible or annual cost-sharing limitation. Individuals ineligible for advance premium tax credits (APTCs) with incomes below 100% and above 250% can qualify for a hardship exemption and enroll in catastrophic coverage when they experience a change in their income.
Effective in plan year 2028, the rule will allow non-network plans to be certified as qualified health plans available on the federal marketplace. Non-network plans set specific benefit amounts for covered services and share those amounts with enrollees, allowing them to compare providers’ prices. Non-network plans would be required to ensure access to providers that accept the plan’s benefit amount as payment in full, including ECPs.
The rule also implements several marketplace-related provisions in the WFTCL, including extending the removal of the 150% federal poverty level special enrollment period, limiting APTC eligibility to “eligible noncitizens,” and ruling immigrants ineligible for Medicaid ineligible for APTCs.
The rule takes effect July 20.
Contact Director of Policy Rob Nelb, MPH, at rnelb@essentialhospitals.org or 202.585.0127 with questions.
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