Patient Protection and Affordable Care Act, HHS Notice of Benefit and Payment Parameters for 2027; and Basic Health Program

The 2027 Payment Notice proposed rule displayed at the Federal Register on February 9, 2026, and published in the Federal Register on February 11, 2026. The comment period closed on March 13, 2026, 32 days after the rule displayed and 30 days after it published in the Federal Register. We summarize and respond to the public comments received regarding the length of the public comment period below.

Comment: A few commenters stated that a 30-day comment period was insufficient given the proposed rule's length and complexity, stating that it did not allow adequate time for researchers, practitioners, and the public to thoroughly read, analyze, and provide meaningful feedback on complex proposals. One comment letter alleged HHS withheld data relevant to understanding the proposals and that withholding this information denied the public a reasonable opportunity to comment. Commenters suggested that HHS either extend the comment period or set aside consideration of less-developed proposals in favor of expediting publication of the final rule and its standards affecting coverage requirements for PY 2027 and PY 2028 and implementing the WFTC legislation.

Commenters also raised concerns that the late publication of the proposed rule creates serious downstream implementation challenges, leaving State agencies, issuers, and other interested parties without enough time to address final rule policies before critical filing deadlines. One commenter stated that because the comment period would end just 2 months before the mid-May 2026 deadline for Affordable Care Act plans to file rates in their States, there would be little time for State insurance regulators to publish guidance for issuers that reflect the provisions of the final rule.

Response: We disagree that interested parties had insufficient time to meaningfully consider and comment on the proposed rule. Thirty days has become the standard length of this annual rulemaking's comment period, setting an expectation which prepares commenters, especially in the individual market health insurance industry, to provide meaningful comments within the allotted time. We received over 5,029 comments addressing every substantive proposal in the 2027 Payment Notice proposed rule, including comments from individuals, State governments or entities, national professional organizations, issuers and issuer groups, providers/provider groups/provider associations, general advocacy groups, agents/brokers, disease advocacy groups, pharmaceutical companies and groups, tribal organizations, dental organizations, labor groups, and other organizations, and approximately 2,169 form letters. These comments demonstrate that individuals and organizations alike were able to submit meaningful comments within the comment period and do not support an extension of the comment period or assertions that the public lacked a meaningful opportunity to comment.

Further, we did not withhold information on which the proposals in the proposed rule relied. As commenters acknowledged, the proposed rule referenced data relevant to the proposed policies, including data we previously made available through public use files and other publications. To the extent any interested parties had questions about data cited in the proposed rule or required any further information, the proposed rule invited parties to contact HHS during the comment period. Notably, no commenter suggested they sought data from HHS during the comment period and was denied. For this reason, we do not agree that HHS withheld data impeding the public's ability to meaningfully comment on the proposed rule.

We acknowledge the importance of finalizing this rule as soon as possible and prior to critical deadlines for submission of health insurance rates to Federal and State regulators. Rate setting and plan finalization for PY 2027 depends on the finalization of the policies set forth in this final rule (such as permissible cost sharing parameters and the submission of rate filing justifications). Consistent with comments outlining concerns about impending critical rate filing deadlines, if we were to extend the comment period, the publication of the final rule would be further delayed. To provide individual and small group market issuers sufficient time to develop and price plan offerings for PY 2027 and because it is imperative that these rules be finalized as soon as possible, we set a 30-day comment period for the proposed rule.

We stated in the proposed rule that, as demonstrated by the number of distinct programs addressed in that rulemaking and the structure of the proposed rule in addressing them independently, we generally intended the rule's provisions, if finalized, to be severable from each other. For example, the proposed rule outlines proposed payment parameters and provisions for the HHS-operated risk adjustment program and HHS-RADV, the 2027 user fee rate for issuers in the risk adjustment program, the 2027 FFE and SBE-FP user fee rates, and provisions related to administration of CMPs. We also proposed, among other proposals, to disallow APTC for individuals who are ineligible for Medicaid due to their immigration status and have income below 100 percent of the FPL for taxable years beginning after December 31, 2025, limit APTC eligibility among aliens lawfully present who are not “eligible aliens” effective January 1, 2027, and extend the removal of the 150 percent FPL SEP beyond PY 2026 to align with the WFTC legislation. We stated that in the proposed rule that we believe the proposed provisions, if finalized, are generally capable of functioning sensibly on an independent basis. We stated that it is our intent that if any provision of the proposed rule, if finalized, is held to be invalid or unenforceable by its terms, or as applied to any person or circumstance, the other provisions in the proposed rule shall be construed so as to continue to give maximum effect as permitted by law, unless the holding shall be one of utter invalidity or unenforceability. We stated that in the event a provision if finalized is found to be utterly invalid or unenforceable, we intend for that provision to be severable.

We sought comment on the severability of these provisions in the proposed rule and did not receive any comments in response. For the reasons outlined in the proposed rule and in this final rule, we are finalizing this policy as proposed.

To derive wage estimates, we generally use data from the Bureau of Labor Statistics to derive labor costs (including a 100 percent increase for the cost of fringe benefits and overhead) for estimating the burden associated with the ICRs.\369\ Table 14 presents the median hourly wage, the cost of fringe benefits and overhead, and the adjusted hourly wage.

\369\ See U.S. Bureau of Labor Statistics (n.d.). Occupational Employment and Wage Statistics, May 2024 Occupation Profiles. Dep't. of Labor. https://www.bls.gov/oes/current/oes_stru.htm.

As indicated, employee hourly wage estimates have been adjusted by a factor of 100 percent. This is necessarily a rough adjustment, both because fringe benefits and overhead costs vary significantly across employers, and because methods of estimating these costs vary widely across studies. Nonetheless, there is no practical alternative, and we believe that doubling the hourly wage to estimate total cost is a reasonably accurate estimation method.

[GRAPHIC] [TIFF OMITTED] TR20MY26.029

We proposed to adopt an hourly value of time based on after-tax wages to quantify the opportunity cost of changes in time use for unpaid activities (91 FR 6424). This approach matches the default assumptions for valuing changes in time use for individuals undertaking administrative and other tasks on their own time, which are outlined in an Assistant Secretary for Planning and Evaluation (ASPE) report on “Valuing Time in U.S. Department of Health and Human Services Regulatory Impact Analyses: Conceptual Framework and Best Practices.” \370\ We start with a measurement of the usual weekly earnings of wage and salary workers of $1,206.\371\ We divide this weekly rate by 40 hours to calculate an hourly pre-tax wage rate of approximately $30.15. We adjust this hourly rate downwards by an estimate of the effective tax rate for median income households of about 17 percent, resulting in a post-tax hourly wage rate of approximately $25.02. We adopt this as our estimate of the hourly value of time for changes in time use for unpaid activities.

\370\ Office of the Assistant Secretary for Planning and Evaluation. (2017, Sept. 17). Valuing Time in U.S. Department of Health and Human Services Regulatory Impact Analyses: Conceptual Framework and Best Practices. Dep't of HHS. https://aspe.hhs.gov/reports/valuing-time-us-department-health-human-services-regulatory-impact-analyses-conceptual-framework.

\371\ U.S. Bureau of Labor Statistics. Employed full time: Median usual weekly nominal earnings (second quartile): Wage and salary workers: 16 years and over [LEU0252881500A], retrieved from FRED, Federal Reserve Bank of St. Louis. https://fred.stlouisfed.org/series/LES1252881500Q. Annual Estimate, 2024.

We sought comment on these burden estimates and assumptions.

We did not receive any comments in response to these proposed burden estimates. For the reasons outlined in the proposed rule, we are finalizing these estimates as proposed.

In the proposed rule, we stated that under Sec. 154.215(b)(1) through (3) and CMS' Unified Rate Review Instructions,\372\ issuers are required to submit a rate filing justification that consists of three parts: (1) the URRT; (2) a written description justifying any premium rate increase when a plan within a product has a rate increase that is subject to review; and (3) an Actuarial Memorandum when a plan within a product has a rate increase, regardless of the size of the increase, when a product contains a QHP, or when a State requires it (91 FR 6425). Section 156.80(d)(2)(i) specifies that the actuarially justified plan-specific factors by which an issuer may vary premium rates for a particular plan from its market-wide index rate include the actuarial value and cost-sharing design of the plan, including, if permitted by the applicable State authority, accounting for CSR amounts provided to eligible enrollees under Sec. 156.410, provided the issuer does not otherwise receive reimbursement for such amounts.

\372\ See Unified Rate Review Instructions at https://www.cms.gov/files/document/unified-rate-review-instructions.pdf.

As discussed in the proposed rule, CSR loading is a permissible practice if permitted by the State and the amounts are actuarially justified plan-level adjustments which issuers must report when they submit a rate filing to the State or CMS for review, to ensure compliance with the Federal rating rules, including Sec. 156.80. To provide regulators with information to help determine whether CSR loads are actuarially justified, this rule finalizes our proposal that the actual CSR amount paid on behalf of eligible enrollees and the additional revenue collected from the previously applied CSR load be reported on the URRT and calculated using the most recent annual data that

is available prior to the applicable filing year, using the standard methodology set forth in Sec. 156.430(c)(2).

Assuming a cross-functional team, we estimate that issuers will incur an initial one-time cost and burden in 2026 to develop and implement a claim-level re-adjudication process using the standard methodology set forth in Sec. 156.430 to produce the required values. We estimate that for each issuer it will require 2,400 hours (at an hourly rate of $120.94) for Actuaries to define the plan mappings and business rules and set reasonableness thresholds, 3,000 hours (at an hourly rate of $108.26) for Data Scientists to design the approach and data flows, prototype the logic, and validate results, 3,000 hours (at an hourly rate of $94.88) for Computer Programmers to develop and maintain the production code and workflows, automate runs, and ensure reliability and performance, 2,000 hours (at an hourly rate of $73.84) for Claims Specialists to assemble and interpret claims, eligibility, and accumulator data, and 1,000 hours (at an hourly rate of $96.88) for a Project Manager to coordinate timelines, handoffs, and deliverables to produce the experience-period actual CSR amount paid on behalf of eligible enrollees (using the most recent annual data available, generally 2 years before the upcoming plan year, using the CMS standard methodology set forth in Sec. 156.430(c)(2)), the additional revenue collected from the previously applied CSR load from the most recent annual data available, the projection-period expected CSR amount to be paid on behalf of enrollees for the upcoming plan year, and the plan- level CSR load factor for the upcoming plan year, and additional revenue expected to be collected from the applied CSR load factor for the upcoming plan year for URRT reporting, resulting in a total one- time burden of 11,400 hours, with an associated cost of approximately $1,144,236. For all 366 issuers, we estimate a total burden of 4,172,400 hours, with an associated cost of approximately $418,790,376. [GRAPHIC] [TIFF OMITTED] TR20MY26.030

In subsequent years, we assume that issuers will require targeted updates to ensure their systems are accurately calculating the required values using the most recent data. We estimate that for each issuer it will require 1,200 hours (at an hourly rate of $120.94) for Actuaries to update plan parameters and CSR-to-standard-plan mappings using the most recent annual data that is available prior to the applicable filing year, 1,500 hours (at an hourly rate of $108.26) for Data Scientists to update specifications, oversee execution, and review outputs, 1,500 hours (at an hourly rate of $94.88) for Computer Programmers to reload data, apply configuration and code updates, and run and monitor the processing, 1,000 hours (at an hourly rate of $73.84) for Claims Specialists to reconcile corrected claims, and 500 hours (at an hourly rate of $96.88) for a Project Manager to manage review and sign-off for the cycle, resulting in an annual ongoing burden of 5,700 hours, with an associated cost of approximately $572,118. For all 366 issuers, we estimate a total burden of 2,086,200 hours, with an associated cost of approximately $209,395,188. [GRAPHIC] [TIFF OMITTED] TR20MY26.031

Some issuers may incur a lower one-time cost if they currently have a system in place that is able to calculate the load factor and other required values using the standard methodology, or if their systems only require updates and minor changes to function properly. We also acknowledge that some issuers may incur higher costs if they are required to develop and build a new system to meet the proposed requirements and calculate the appropriate values. We further acknowledge that some issuers may incur higher or lower annual costs depending on their volume of CSR-eligible claims. 2. ICR Related to the Submission of Unified Rate Review Templates (URRTs)

As discussed in section III.C. of this final rule, this rule finalizes our proposal to change the instructions for the URRT so that issuers will enter the actual amount of CSRs they paid on behalf of eligible enrollees (using the most recent annual data that is available prior to the applicable filing year, generally two years prior to the upcoming plan year), the additional revenue collected from the previously applied CSR load, the amount of CSRs they expect to be paid on behalf of enrollees in the upcoming plan year, the CSR load factor for the upcoming plan year, and the additional revenue expected to be collected from the applied CSR load factor for the upcoming plan year.

Issuers will incur ongoing burden to gather all the required CSR- related data

elements and enter them into the URRT in their appropriate places. We estimate that for each plan an issuer will require 0.5 hours (at an hourly rate of $120.94) for Actuaries to collect all required CSR- related data elements (actual CSR amounts paid on behalf of eligible enrollees, additional revenue collected from the previously applied CSR load, expected CSR amounts to be paid on behalf of enrollees in the upcoming plan year, CSR load factor for the upcoming plan year, and additional revenue expected to be collected from the applied CSR load factor for the upcoming plan year) and ensure the data is accurately entered into the URRT, resulting in an ongoing burden of 0.5 hours, with an associated cost of approximately $60 per plan. We estimate that each issuer will need to submit data for an approximate average of 7 plans \373\ that include CSR load factors and thus will incur an estimated burden of 3.6 hours, with an associated cost of approximately $430.\374\ For all 366 issuers, we estimate a total burden of 1,300 hours, with an associated cost of approximately $157,222.

\373\ Average number of plans per issuer derived from the PY 2025 URRT data using the PUF found at https://www.cms.gov/marketplace/resources/data/rate-review-data.

\374\ Certain values are rounded for readability and are indicated by the use of terms such as 'approximately' or 'average.' All cost and burden calculations are based on unrounded figures to ensure accuracy. [GRAPHIC] [TIFF OMITTED] TR20MY26.032

As discussed in section III.C. of this final rule, this rule finalizes our proposal that information regarding CSR-related plan- level adjustments to the index rate should be provided in the URRT and also provided in the Actuarial Memorandum so that issuers provide numerical values in the URRT and explain how they reached those values in the Actuarial Memorandum.

Issuers will incur additional ongoing burden to develop, draft, and add the explanation of the methodology used to determine the load factor and an explanation of how the additional revenue expected to be collected from the applied CSR load factor for the upcoming plan year compares to the amount of CSRs expected to be paid on behalf of enrollees for the same period. We estimate that for each plan an issuer will require 2 hours (at an hourly rate of $120.94) for Actuaries to develop, draft the required explanations (the methodology used to determine the CSR load factor for the upcoming plan year and an explanation of how the additional revenue expected to be collected from the applied CSR load factor for the upcoming plan year compares to the amount of CSRs expected to be paid on behalf of enrollees for the same period), and add them to the Actuarial Memorandum for submission via SERFF and/or MPMS, resulting in an ongoing burden of 2 hours, with an associated cost of approximately $242 per plan. We estimate that each issuer will need to submit explanations for an average of 7 plans and thus would incur an estimated burden of approximately 14 hours, with an associated cost of approximately $1,718. For all 366 issuers, we estimate a total burden of 5,200 hours, with an associated cost of approximately $628,888.\375\

\375\ Certain values are rounded for readability and are indicated by the use of terms such as `approximately' or `average.' All cost and burden calculations are based on unrounded figures to ensure accuracy. [GRAPHIC] [TIFF OMITTED] TR20MY26.033

The information collection described in this section will be submitted as a revision to the currently approved PRA package CMS-10379 (OMB Control Number 0938-1141) for OMB review under the Paperwork Reduction Act.

Table 19 aggregates the burden and costs from Tables 15 through 18. The 2026 burden (11,418 hours per respondent) includes the one-time implementation (11,400 hours) plus ongoing URRT and Actuarial Memorandum submissions (18 hours total). The 2027-2028 burden (5,718 hours per respondent) includes annual system updates (5,700 hours) plus ongoing URRT and Actuarial Memorandum submissions (18 hours total). The three-year averages are calculated by summing the annual figures and dividing by three.\376\

\376\ Certain values are rounded for readability and are indicated by the use of terms such as 'approximately' or 'average.' All cost and burden calculations are based on unrounded figures to ensure accuracy.

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As discussed in the preamble of this final rule, we are finalizing amendments to Sec. 155.220(j)(2)(ii)(A) and (j)(2)(iii)(A) to require agents, brokers, and web-brokers to use the HHS-approved and -created consumer consent form to meet the eligibility application review documentation requirements and consent documentation requirements. We are finalizing this policy with a modification that it will be effective beginning with PY 2028 instead of PY 2027. Accordingly, we are also finalizing the redesignation of current Sec. 155.220(j)(2)(ii)(A)(2) as Sec. 155.220(j)(2)(ii)(A)(3) and current Sec. 155.220(j)(2)(iii)(C) as Sec. 155.220(j)(2)(iii)(D). We are also finalizing corresponding changes to Sec. Sec. 155.220(j)(2)(ii)(A) and (j)(2)(iii)(A) to state that current documentation policies for eligibility application and review and consent are effective until PY 2028. Our finalized policy will eliminate the current broad allowances for meeting these requirements. The language in the regulation will also be changed to clarify what types of actions constitute “taking an action” to meet the regulatory requirements. As discussed in the proposed rule, the goal of this policy is to reduce confusion among agents, brokers, and web-brokers on what constitutes compliant eligibility application review documentation and what constitutes compliant consumer consent by ensuring objective standards, which ultimately protects consumers (91 FR 6427). These finalized policies will also greatly improve HHS' investigative abilities into agent, broker, and web-broker eligibility application review documentation and consumer consent documentation review by creating a clear and objective standard for all applications clearly outlining what HHS deems complaint.

We estimate there will be very minimal costs in time associated with this policy as agents, brokers, and web-brokers are already required to document and maintain eligibility application review documentation information and consumer consent documentation information. As a result, this policy will not add to those requirements, rather, it will only require that a specific form be used.

In the proposed rule, we stated that according to our records, as of September 18, 2025, there are a total of 105,988 agents, brokers, and web-brokers who have presently completed the FFE training who are registered to assist consumers on the Exchanges. Under our records, the percentage of agents, brokers, and web-brokers that currently submit only audio files for eligibility application review documentation and consumer consent documentation is approximately 24 percent, which equals 25,437 agents, brokers, and web-brokers who are utilizing this method. Additionally, per our records, the percentage of agents, brokers, and web-brokers that currently submit partial audio files in connection with eligibility application review documentation and consumer consent documentation is approximately 42 percent, which equals 44,514 agents, brokers, and web-brokers who are utilizing this method.

Regarding the costs related to requiring agents, brokers, and web- brokers to use the HHS-approved and -created consumer consent form to meet the eligibility application review

documentation requirements and the consumer consent documentation requirements, we estimate it would take approximately 10 minutes of time for an enrolling agent, broker or web-broker to meet eligibility application review documentation requirements and to obtain consumer, or their authorized representative, affirmation of their consent. Using the current adjusted hourly wage rate of $58.04 \377\ for an insurance sales agent, each enrollment using the HHS-approved and -created consumer consent form would have approximately $9.87 (10 minutes, or 0.17 hours, at an hourly wage rate of $58.04) in additional cost associated with it based on the extra time commitment from these proposed policy changes. In PY 2024, agents submitted 9,800,000 policies. Based on this number of enrollments, the total annual burden is 1,666,000 hours (9,800,000 submitted policies x approximately 0.17 hours) with a total annual cost of $96,694,640 (1,666,000 hours x $58.04 per hour).

\377\ See the U.S. Bureau of Labor Statistics (n.d.). Occupational Employment and Wage Statistics, May 2024 Occupation Profiles. Dep't. of Labor. https://www.bls.gov/oes/current/oes_stru.htm.

Under the finalized policy, HHS will require agents, brokers, and web-brokers to use the HHS-approved and -created consumer consent form to meet the eligibility application review documentation requirements and the consumer consent documentation requirements. The HHS-approved and -created consumer consent form can be submitted electronically, so there will be no costs associated with printing or mailing the HHS- approved and -created consumer consent form.

The estimated cost of requiring agents, brokers, and web-brokers to use the HHS-approved and -created consumer consent form to meet the eligibility application review documentation requirements and the consumer consent documentation requirements is $96,694,640.

Because we are finalizing this proposal, the new information collection requirements discussed in this section will be submitted for OMB review and approval in a new PRA package.

We sought comment on these burden estimates and assumptions.

We did not receive any comments in response to the proposed burden estimates for this policy. For the reasons outlined in the proposed and this final rule, we are finalizing these estimates with the modification to implement the policy effective PY 2028.

As discussed in the preamble of this final rule, we are finalizing amendments to Sec. 155.220(j), creating new standards of conduct section on marketing requirements, which would be housed in Sec. 155.220(j)(3). These new regulations will prohibit agents, brokers, and web-brokers from engaging in misleading marketing, while adhering to the requirements in newly proposed Sec. 155.220(j)(3)(iii), and require agents, brokers, and web-brokers to provide marketing materials to HHS upon request. We estimate costs that would be associated with this finalized policy are mainly those involved in responding to HHS' requests for documentation. Producing such documentation will require the submission of electronic documents to HHS upon request.

As discussed in the proposed rule, we do not anticipate many costs for the agents, brokers, or web-brokers we investigate for misleading marketing (91 FR 6428). Based on our current investigative methods and volume of misleading advertisements we have uncovered thus far, we currently only plan to send 70 notifications annually to agents, brokers, and web-brokers for misleading marketing. Based on analysis of existing enforcement outreach conducted on misleading marketing, about \2/3\ of the notices we send would be part of our Technical Assistance (TA) enforcement workstream, only requires the agent, broker, or web- broker to indicate the ad(s) has been removed. The other \1/3\ of the notices we send would be Notices of Intent to Terminate (NoITs). NoITs require the agent, broker, or web-broker to respond indicating (1) they removed the ad(s) in question and (2) they reviewed the marketing guidelines CMS sent them. Therefore, there would only be approximately 24 notifications sent annually that require agents, brokers, or web- brokers to submit documentation in response to HHS. We are finalizing our proposal to allow HHS to request and review advertisements in new Sec. 155.220(j)(3)(iv). If HHS were to utilize this regulatory authority and request advertisements from an agent, broker, or web- broker, it would be part of our NoIT requirements and the same 24 agents, brokers, or web-brokers would be impacted.

We believe responding to HHS requests to provide confirmation they removed the ads and/or reviewed the marketing guidelines would not be overly time-consuming or burdensome. Our notifications to the agents, brokers, or web-brokers detail what response is required and provide hyperlinks to the noncompliant ad(s). We estimate it would take each agent, broker, or web-broker one hour to remove any noncompliant ad(s), and/or review the marketing guidelines, and respond to HHS via email. This estimate incorporates the potential of HHS asking these 24 agents, brokers, and web-brokers to provide advertisements for HHS' review. Using the hourly wage rate for an insurance sales agent from Table 14, this means the total burden of responding to HHS regarding misleading marketing would be 24 hours at a cost of $1,392.96 ($58.04 per hour x 1 hour x 24 responses), beginning in 2027.

We sought comment on these burden estimates and assumptions.

We did not receive any comments in response to the proposed burden estimates for this policy. For the reasons outlined in the proposed rule, we are finalizing these estimates as proposed.

The following changes will be submitted for review under OMB Control Number 0938-1218 for BHP. We explained in the proposed rule that because section 71301 of the WFTC legislation amended section 36B of the Code to provide that PTC is not allowed

for the coverage of noncitizens who are lawfully present but not “eligible aliens,” this population is no longer allowed PTC for their coverage beginning January 1, 2027, and as such, States will no longer receive Federal payments associated with members of this population who are BHP enrollees effective January 1, 2027 (91 FR 6429). States that operate a BHP will need to modify enrollment data sent to CMS in accordance with this provision to enable CMS to accurately calculate the State's BHP funding.

We estimate that implementing this policy would require ongoing costs for States to submit additional enrollment data to CMS. We estimate that it would take a Business Operations Specialist 2.5 hours at $78.14 per hour and a General Manager 0.5 hours at $99 per hour to compile and submit additional quarterly estimated enrollment data. We estimate that it would take a Business Operations Specialist 25 hours at $78.14 per hour and a General Manager 2.5 hours at $99 per hour to compile and submit additional quarterly final enrollment data. For the three States and DC currently approved to operate a BHP in 2027 we estimate the total annual ongoing cost to be $39,133.60.

We sought comment on these burden estimates and assumptions.

We did not receive any comments in response to these proposed burden estimates. For the reasons outlined previously and in the proposed rule, we are finalizing these estimates as proposed. 2. Exchanges

The following changes will be submitted for review under OMB Control Number 0938-NEW for Exchanges and OMB Control Number 0938-1218 for BHP.

As discussed in section III.D.8. of this final rule, we are finalizing our proposal to align Exchange eligibility and verification rules with section 71301 of the WFTC legislation, which disallows PTC for the coverage of noncitizens other than “eligible aliens.” We are adding a new definition of “eligible noncitizen” at Sec. 155.20 and updating our regulations at Sec. 155.305(f)(1)(ii) to align with 26 CFR 1.36B-1(d) and Sec. 155.305(f)(1)(ii)(C) to clarify that an Exchange must grant eligibility for APTC to individuals defined as “U.S. citizens, U.S. nationals, and eligible noncitizens,” provided the other APTC eligibility requirements are met. For BHP, we are finalizing our proposal to add a new definition of “eligible noncitizen” at 42 CFR 600.5 that cross-references to Sec. 155.20. These changes are effective beginning in PY 2027 and will apply to the 22 State Exchanges expected to be operating in PY 2027, Exchanges on the Federal platform, and to the three States that are currently approved to operate a BHP (Minnesota, Oregon, and New York), as well as the District of Columbia.\378\

\378\ CMS. (2025, August 4). Fact Sheets & Frequently Asked Questions (FAQs): State-based Exchanges. https://www.cms.gov/cciio/resources/fact-sheets-and-faqs/state-marketplaces.

To implement these changes, in the proposed rule we stated that the Federal Data Services Hub would need to make updates to its Verify Lawful Presence (VLP) service, to enable Exchanges to accurately verify whether an individual is an eligible noncitizen (91 FR 6429). In addition, we also stated that Exchanges on the Federal platform and the 22 State Exchanges would need to update their eligibility and enrollment systems to collect applicant attestations regarding eligible noncitizen status, to correctly determine APTC and income-based CSR eligibility on the basis of such attestations, to determine whether such attestations can be considered verified, to set and process new inconsistencies in cases where such attestations cannot be verified. Exchanges would also need to ensure that current enrollees who would no longer be eligible for APTC or income-based CSRs as a result of this finalized policy have their APTC and CSR eligibility ended accordingly. 3. Implementation Costs

We estimate that implementing this policy will require one-time costs for the Federal Government to make technical updates to its system. Based on preliminary analysis, we estimate that it would take the Federal Data Services Hub (the “Hub”) 2,000 hours in 2026 to make these technical updates. Of the 2,000 hours for Hub updates, we estimate it would take a database and network administrator and architect 500 hours at $103.34 per hour and a computer programmer 1,500 hours at $94.88 per hour. Given this, to make Hub updates, we estimate that the Federal Government would incur a one-time burden in 2026 of $193,990 [(500 hours x $103.34 + (1,500 hours x $94.88)] to make these system updates.

We also estimate that it will take Exchanges on the Federal platform 7,000 hours to make the updates required to implement this provision. Of the 7,000 hours required to make updates for Exchanges on the Federal platform, we estimate that it would take a database and network administrator and architect 1,750 hours at $103.34 per hour and a computer programmer 5,250 hours at $94.88 per hour. Given this, Exchanges on the Federal platform would incur a one-time burden of $678,965 [(1,750 hours x $103.34) + (5,250 hours x $94.88)].

Similar to the one-time costs incurred by Exchanges on the Federal platform, we estimate that implementing this policy will require one- time costs for each State Exchange of 7,000 hours. Of these 7,000 hours, we estimate it would take a database and network administrator and architect 1,750 hours at $103.34 per hour and a computer programmer 5,250 hours at $94.88 per hour to make the changes. State Exchanges would therefore incur a one-time burden of $14,937,230 [(1,750 hours x $103.34) + (5,250 hours x $94.88)] x 22 State Exchanges) to implement these technical changes.\379\

\379\ Section 3 figures are based on labor needs estimates internal to the FFM as well as Table 14: Adjusted Hourly Wages Used in Burden Estimates.

We anticipate that this finalized policy will result in ongoing burden reduction for Exchanges on the Federal platform related to no longer generating Medicaid Lawful Presence (MLP) Data Matching Issues (DMIs) and for all Exchanges related to no longer generating annual income (AI) DMIs for those who attest to income under 100 percent of the FPL. We noted in the proposed rule that these DMIs are generated when an individual attests that they are a lawfully present noncitizen and have an attested household income under 100 percent of the FPL, but the Exchange is not able to verify promptly whether their immigration status disqualifies them from full Medicaid coverage or verify their attested annual household income with trusted data sources (91 FR 6430). We also stated that currently, Exchanges must require individuals to submit documentation to verify their attested application information when trusted data sources cannot verify. 3. Medicaid Lawful Presence (MLP) Data Matching Issue (DMI) Reduction

These inconsistencies are not generated by State Exchanges, so we do not estimate any change in burden to State Exchanges. Based on historical data from the FFE, we estimate a reduction of approximately 275,000 inconsistencies \381\ at the consumer level for the Exchanges on the Federal platform. The change would result in a decrease in burden on the Exchanges on the Federal platform. Once households have submitted the required verification documents, we estimate that it takes approximately 1 hour and 12 minutes (or 1.2 hours) for an eligibility support staff person (BLS occupation code 43-4061), at an hourly cost of $49.52,\382\ to receive, review, and verify submitted verification documents as well as conduct outreach and determine DMI outcomes. The revisions to Sec. 155.305 would result in a decrease in annual burden for the Federal government of 330,000 hours (275,000 inconsistencies at the consumer level x 1.2 hours) with savings of $16,341,600 (330,000 hours x $49.52 hourly wage rate).

\381\ This estimate is based on internal FFM data.

\382\ See Table 14: Adjusted Hourly Wages Used in Burden Estimates.

Based on historical data from the FFE, we estimate that approximately 77,000 inconsistencies \383\ would not be generated at the household level for the Exchanges on the Federal platform. On the State Exchanges, we estimate this figure to be 54,000 inconsistencies.\384\ The change would result in a decrease in burden on Federal and State Exchanges. Once households have submitted the required verification documents, we estimate that it would take approximately 1 hour and 12 minutes (or 1.2 hours) for an eligibility support staff person (BLS occupation code 43-4061), at an hourly cost of $49.52,\385\ to receive, review, and verify submitted verification documents as well as conduct outreach and determine DMI outcomes. Therefore, removing these inconsistencies would result in a decrease in burden on the Federal Government of 92,400 hours (77,000 verifications x 1.2 hours per verification) with savings of $4,575,648 (92,400 hours x $49.52 per hour), and a decrease in burden on the State Exchanges of 64,800 hours (54,000 verifications x 1.2 hours per verification) with savings of $3,208,896 (64,800 hours x $49.52 per hour), and the cost decrease across all Exchanges would be approximately $7,784,544 (157,200 hours x $49.52 hourly cost of eligibility support staff person).

\383\ This estimate is based on internal FFM data.

\384\ This population estimate is based on internal CMS data.

\385\ See Table 14: Adjusted Hourly Wages Used in Burden Estimates.

The total estimated annual reduction in burden for these information collection requirements, beginning in 2026, is $24,126,144 ($16,341,600 + $7,784,544), representing 487,200 (330,000 + 157,200) hours of burden across all affected entities.

We sought comment on these proposed burden estimates and assumptions.

We did not receive any comments in response to the proposed burden estimates for this policy. For the reasons outlined previously and in the proposed rule, we are finalizing these estimates as proposed.

We are finalizing our proposal to amend paragraph Sec. 155.305(f)(4) so that in PY 2028 and beyond, all Exchanges may not determine a tax filer or their enrollee eligible for APTC if: (1) HHS notifies the Exchange that APTC were paid on behalf of the tax filer, or their spouse if the tax filer is a married couple, for one year for which tax data would be utilized for verification of household and family size, and (2) the tax filer did not comply with the requirement to file a Federal income tax return and reconcile APTC for that year (referred to as the “1-tax year FTR” process). We also are finalizing that at the option of the Exchange, an Exchange may choose to implement this policy earlier in PY 2027 if it has the resources and capability to adopt the 1-year FTR process or continue to follow the 2-year FTR process until PY 2028. Exchanges on the Federal platform intend to adopt the 1-year FTR process in PY 2027, as HHS has the resources possible to do so. As we noted in the proposed rule, section 71303(a)(6) of the WFTC legislation amended section 36B(c) of the Code such that term “coverage month” does not include, for any individual enrolled in a QHP through an Exchange, any month for which the Exchange does not meet the requirements of Sec. 155.305(f)(4)(iii) as published in the 2025 Marketplace Integrity and Affordability final rule (90 FR 27074) for PY 2028 and beyond, where effectively Exchanges are required to find enrollees ineligible for APTC after they or their tax filer has failed to file and reconcile their APTC for 1-tax year (91 FR 6430). However, minimal changes to the language of the Exchange application questions for States served by HealthCare.gov will be necessary to obtain relevant information; as such, we anticipate that the amendment finalized in this rule will not impact the information collection burden for consumers. We anticipate that for some Exchanges, there will no longer be a 2-year FTR population for PY 2027, and thus the notices sent to the 1-year FTR population will be similar to the current 2-tax year FTR notices in inciting an urgency to act. Other Exchanges may

choose to delay the change until PY 2028, but that all consumers with an FTR status will be in a 1-tax year FTR status for PY 2028. Due to this, we do not anticipate PRA impacts related to noticing requirements (OMB Control Number: 0938-1207).

We sought comment on these proposed burden estimates and assumptions.

We did not receive any comments in response to the proposed burden estimates for this policy. For the reasons outlined in the proposed rule, we are finalizing these estimates as proposed.

We are finalizing our proposal to update Sec. 155.320(c)(3)(iii)(A) to extend the requirement for applicants to submit documentation when their attested household income is within the APTC range, but data sources indicate income less than 100 percent of the FPL. As finalized in the 2025 Marketplace Integrity and Affordability final rule (90 FR 27074), Exchanges are required to generate income DMIs when a tax filer's attested annual household income would qualify the taxpayer as an applicable taxpayer according to 26 CFR 1.36B-2(b) and trusted data sources indicate that income is under 100 percent of the FPL only through PY 2026. In the proposed rule, we stated that we proposed to implement this policy as a new and permanent verification process within the Exchange, as detailed later (91 FR 6431).

We anticipate that extending this income verification requirement would result in approximately 1 hour of time spent by consumers to complete associated questions in the application or to submit supporting documentation for each year of operation. Based on historical data from the FFE, we estimate that approximately 340,000 inconsistencies would be generated at the household level for the Exchanges on the Federal platform annually starting in 2027. On the State Exchanges, we estimate this figure to be 208,000 inconsistencies annually starting in 2027. Therefore, adding these inconsistencies would increase burden on consumers by approximately 548,000 hours across all Exchanges. Using the estimate of the hourly value of time for changes in time use for unpaid activities calculated at $25.02 per hour in section IV.A. of this final rule, we estimate that the increase in cost for each consumer in 2027 would be approximately $25.02, and the cost increase for all consumers who would generate this income inconsistency in 2027 and onwards would be approximately $13,710,960 (548,000 hours x $25.02 cost of unpaid activities) per year.

Additionally, we estimate that adding this income verification requirement would result in an increase in burden on the Exchanges on the Federal platform. Once households have submitted the required verification documents, we estimate that it would take approximately 1 hour and 12 minutes (1.2 hours) for an eligibility support staff person (BLS occupation code 43-4061), at an hourly cost of $49.52,\386\ to receive, review, and verify submitted verification documents as well as conduct outreach and determine DMI outcomes. Therefore, adding these inconsistencies would result in an increase in annual burden on Exchanges on the Federal platform of 408,000 hours (340,000 verifications x 1.2 hours per verification) at a cost of $20,204,160 (408,000 hours x $49.52 per hour) starting in 2027, and an increase in annual burden on the State Exchanges of 249,600 hours (208,000 verifications x 1.2 hours per verification) at a cost of $12,360,192 (249,600 hours x $49.52 per hour) starting in 2027.

\386\ See Table 14: Adjusted Hourly Wages Used in Burden Estimates.

In addition to these administrative costs, we anticipate system expenses occurring in 2026 to establish this policy ahead of the effective date in 2027. These costs are to support updating technical systems, including the eligibility system. In the 2025 Marketplace Integrity and Affordability final rule (90 FR 27185), we estimated that it would take the Exchanges on the Federal platform and each State Exchange 8,000 hours in 2026 to make these updates and sunset the policy. Of those 8,000 hours, we estimated that it would take a database and network administrator and architect 2,000 hours at $103.34 per hour and a computer programmer 6,000 hours at $94.88 per hour. Given this, we estimate that Exchanges on the Federal platform would incur a one-time burden in 2026 of $775,960 (2,000 x $103.34 + 6,000 x $94.88) to make these eligibility system updates. State Exchanges would incur a one-time burden of $16,295,160 ((2,000 x $103.34 + 6,000 x $94.88) x 21). Because we are now finalizing this as a new and permanent verification process within the Exchange, we anticipate that many State Exchanges and the Federal Platform would incur the totality of these expenses to implement this policy as finalized.

We sought comment on these proposed burden estimates and assumptions.

We summarize and respond to public comments received on the burden estimates proposed policy in section V.C.14. of this final rule. For reasons outlined in the proposed and final rules, we are finalizing these estimates as proposed.

We are finalizing our proposal to remove Sec. 155.320(c)(5), which will allow Exchanges to continue the income verification process when IRS is successfully contacted but IRS returns no data rather than accepting an applicant's annual household income attestation. We are implementing this policy as a new permanent verification procedure, and we are presenting these estimates as costs inherent to implementing the policy as finalized in this final rule.

In the proposed rule, we stated that based on internal historical DMI data, we estimate that approximately 1,722,000 inconsistencies will be generated annually at the household level for Exchanges on the Federal platform, and 1,056,000 will be generated at the household level for State Exchanges due to this final policy (91 FR 6431). Once households have submitted the required verification documents, we estimate that it will take approximately 1 hour and 12 minutes (1.2 hours) for an eligibility support staff person (BLS occupation code 43- 4061), at an hourly cost of $49.52,\387\ to receive, review, and verify submitted verification documents as well as conduct outreach and determine DMI outcomes. Therefore, the removal of Sec. 155.320(c)(5) will result in an increase in annual burden for Exchanges on the Federal platform of 2,066,400 hours (1,722,000 verifications x 1.2 hours per verification) at a cost of $102,328,128 (2,066,400 hours x $49.52 per hour) starting in 2027 and an increase in annual burden on State Exchanges of 1,267,200 hours (1,056,000 verifications x 1.2 hours per verification) at a cost of $62,751,744 (1,267,200 hours x $49.52 per hour) starting in 2027.

\387\ See Table 14: Adjusted Hourly Wages Used in Burden Estimates.

In addition to the increased administrative burden on Exchanges, this change will increase the number of consumers who are required to submit documentation to verify their income. We estimate that consumers will each

spend 1 hour to answer the associated question, or to submit documentation. Based on historical data from the FFE, we estimate that approximately 2,777,000 inconsistencies will be generated at the household level across all Exchanges yearly. Using the estimate of the hourly value of time for changes in time use for unpaid activities calculated at $25.02 per hour in section IV.A. of this final rule, we estimate that the increase in annual cost for each consumer starting in 2027 will be approximately $25.02 and that the finalized change will increase burden on consumers by 2,777,000 hours per year at an associated cost of $69,480,540 (2,777,000 hours x $25.02 per hour).

In addition to these administrative costs, we anticipate system expenses occurring in 2026 to establish this policy ahead of the effective date in 2027. We estimated that it will take Exchanges on the Federal platform and each State Exchange 9,000 hours in 2026 to implement this policy. Of those 9,000 hours, we estimated it will take a database and network administrator and architect 2,250 hours at $103.34 per hour and a computer programmer 6,750 hours at $94.88 per hour. Therefore, we estimated that Exchanges on the Federal platform will incur a one-time burden in 2026 of $872,955 (2,250 x $103.34 + 6,750 x $94.88) to make these eligibility system updates, and State Exchanges will incur a one-time burden total in 2026 of $18,332,055 ($872,955 x 21) associated with a total of 189,000 (9,000 x 21) burden hours. Because this finalized policy will be implemented as a new permanent verification procedure, we anticipate that the full costs described in this provision will be applied to the State Exchanges and Exchanges on the Federal platform prospectively.

We sought comment on these proposed burden estimates and assumptions.

We summarize and respond to public comments received on the burden estimates proposed policy in section V.C.15. of this final rule. For the reasons outlined in the proposed and final rules, we are finalizing these estimates as proposed.

In this final rule, we are finalizing the provision allowing the Federal Exchange to conduct pre-enrollment verification for SEPs other than Loss of Minimum Essential Coverage and adding the requirement that Exchanges on the Federal Platform conduct pre-enrollment verification for at least 75 percent of new enrollments.

In the proposed rule, we stated that we anticipate that maintaining this expansion of pre-enrollment verification for SEPs would result in approximately 1 hour of time spent by consumers to complete associated questions in the application or submit supporting documentation (91 FR 6432). Based on historical data from the FFE, we estimate that approximately 293,073 new SEP verification issues would continue to be generated at the household level for Exchanges on the Federal platform. Therefore, maintaining these inconsistencies would continue to increase burden on consumers by approximately 293,073 hours. Using the estimate of the hourly value of time for changes in time use for unpaid activities calculated at $25.02 per hour in section IV.A, we estimate that the cost increase for all consumers who generate this income inconsistency would be approximately $7,332,686 annually starting in 2027.

Additionally, we estimate that maintaining expanded pre-enrollment verification for SEPs would result in an increase in burden on Exchanges using the Federal platform. Based on historical FFE data, we anticipate that approximately 293,073 inconsistencies would be generated at the household level for Exchanges on the Federal platform. Once households have submitted the required verification documents, we estimate that it would take approximately 12 minutes (0.2 hours) for an eligibility support staff person (BLS occupation code 43-4061), at an hourly cost of $49.52,\388\ to review and verify submitted verification documents. Therefore, expanding verification would result in an increase in burden on Exchanges on the Federal platform of 58,615 hours (293,073 verifications x 0.2 hours per verification) at a cost of $2,902,615 (58,615 hours x $49.52 per hour) annually starting in 2027.

\388\ See Table 14: Adjusted Hourly Wages Used in Burden Estimates.

We sought comment on these proposed burden estimates and assumptions.

After consideration of comments and for the reasons outlined in the proposed rule and this final rule, including our responses to comments, we are finalizing these burden estimates for this policy as proposed. We summarize and respond to public comments received on the proposed estimates below.

Comment: Several commenters stated concern that expanding SEPV would increase the burden on Exchanges using the Federal platform, which could potentially result in delayed coverage and discourage enrollment. Commenters also stated that the proposed estimates did not account for additional expenditures related to consumer communications, outreach, and assister training.

Response: We agree that expanding SEPV will increase the burden on Exchanges using the Federal platform. Our estimates are based on historical data from the FFE, and we anticipate that the expansion of SEPV will result in an increase in annual labor burden on Exchanges using the Federal platform at an estimated cost of $2,902,615 annually.

Under this finalized policy, individuals who are ineligible for APTC or CSRs due to projected household income may apply for a hardship exemption to qualify for catastrophic coverage. While the FFE automatically grants these exemptions through the application system when consumers apply for catastrophic coverage, some consumers may submit paper applications for hardship exemptions.

In the proposed rule, we stated that the burden associated with this requirement includes the time for consumers to complete and submit paper hardship exemption applications, and the time for Exchanges to review and process these applications.\389\

\389\ 91 FR 6292, 6432 (Feb. 11, 2026).

This information collection is currently approved under OMB control number 0938-1191 (CMS-10440), which covers hardship exemption applications and related documentation.\390\ The finalized expansion of hardship exemption eligibility will not create a new information collection but will expand the scope of an existing collection to include a new category of eligible applicants.

\390\ Exemption forms and related information are approved under OMB control number 0938-1190 (CMS-10466). Information collected through the coverage application and used for the automated exemption process is approved under OMB control number 0938-1191. See Office of Management and Budget, Information Collection Review, OMB Control No. 0938-1190, available at https://www.reginfo.gov/public/do/PRAOMBHistory?ombControlNumber=0938-1190.

Based on current FFE implementation, we estimate that it will continue to require consumers approximately 16 minutes to complete and submit a paper hardship exemption application.

The four State Exchanges that process their own exemptions-- California,

Connecticut, Maryland, and the District of Columbia--will experience an administrative burden associated with reviewing and processing hardship exemption applications under the expanded eligibility criteria. We estimate that Exchange staff will require approximately 19 minutes to manually review and process each paper hardship exemption application. Using the adjusted hourly wage of $49.52 for Eligibility Interviewers, Government Programs (occupation code 43-4061), we estimate the cost per application to be $15.75 [(19 minutes / 60 minutes) x $49.52/hour].

Based on the FFE implementation data and accounting for the enrollment share of the four State Exchanges that process their own exemptions (estimated at approximately 10 percent of total Exchange enrollment), we estimate these four State Exchanges will collectively process approximately 1,072 applications annually under the expanded hardship exemption eligibility criteria. Using the per-application manual processing cost of $15.75, we estimate the total annual cost burden for these four State Exchanges in total to be approximately $16,884 (1,072 applications x $15.75 per application). Individual State burden would depend on each State Exchange's enrollment volume and the proportion of consumers who fall into the expanded hardship exemption category. States with larger enrollment volumes and higher proportions of consumers with income below 100 percent FPL or above 250 percent FPL may experience higher application volumes than States with smaller enrollment or different demographic characteristics.

We note that the burden estimates presented previously may not reflect the actual burden on both consumers and Exchanges. The FFE experience demonstrates that automated exemption processing significantly reduces the need for manual paper application review. Exchanges may implement similar automated systems that grant hardship exemptions automatically when consumers ineligible for APTC or CSRs due to income apply for catastrophic coverage, thereby eliminating the need for separate exemption applications in most cases. Additionally, State Exchanges currently processing their own exemptions may choose to delegate exemption processing to HHS, which would eliminate the direct administrative burden on the State while ensuring consumers have access to the expanded hardship exemption eligibility. This delegation option is available under existing regulations and would result in zero additional burden to the delegating States.

We sought comment on these assumptions.

We did not receive any comments in response to the proposed burden estimates for this policy. For the reasons outlined in the proposed rule, we are finalizing these estimates as proposed.

In the proposed rule, we stated that the burden associated with QHP issuers and States in State Exchanges and SBE-FPs in implementing changes for PY 2026 to meet time and distance standards at Sec. 155.1050 is covered by the currently approved information collection (OMB Control Number: 0938-1341 (CMS-10592)/Expiration date: April 30, 2027) (91 FR 6433). We sought comment on these proposed burden estimates in the context of the changes at Sec. 155.1050(a)(2) that we proposed in the proposed rule and are now finalizing in this final rule, discussed directly below.

We are finalizing our proposal to amend Sec. 155.1050(a)(2) to eliminate, for plan years beginning on or after January 1, 2027, the requirements under Sec. 155.1050(a)(2)(i) and (ii) for State Exchanges and SBE-FPs to establish and impose quantitative time and distance network adequacy standards for QHPs that are at least as stringent as standards for QHPs participating on the FFEs under Sec. 156.230; instead, we will require that State Exchanges and SBE-FPs ensure that each QHP provides sufficient access to providers in a manner that meets applicable standards specified in Sec. 156.230(a)(1)(ii) and (a)(1)(iii) for network plans, or, for plan years beginning on or after January 1, 2027, Sec. 156.236(a) for non-network plans if such plans are allowed to be offered through the Exchange, as applicable. Many State Exchanges and SBE-FPs demonstrated to HHS that they have robust network adequacy standards and reviews in place beyond the requirements specified in Sec. 156.230(a)(1)(ii) and (a)(1)(iii) for network plans, or Sec. 156.236(a) for non-network plans. This approach recognizes that States are often best positioned to evaluate local provider networks and market conditions.

We estimate there would be minimal increase in burden to issuers associated with the modification of this policy as it was in effect for only one plan year, and prior to PY 2026, each State Exchange and SBE- FP was evaluated by HHS to understand their current state of network adequacy reviews, with all States being deemed as either meeting the requirements described at Sec. 155.1050(a)(2)(i) or were determined to have a network adequacy review in place that met the requirement for the exception described at Sec. 155.1050(a)(2)(ii).

We previously estimated that the total annual burden associated with State Exchanges and SBE-FPs in establishing and conducting network adequacy reviews to be up to 900 hours, which we anticipate would still apply, as we do not anticipate State Exchanges or SBE-FPs would need to make changes to their systems or policies to support the restoration of flexibilities to conduct network adequacy. Assuming the compliance officer average hourly rate of $75.40,\391\ we estimate the cost of the data collection, operations, and maintenance pertaining to these finalized requirements on each State Exchange and SBE-FP would be $67,860 per year (900 hours x $75.40 per hour). In total, for the 22 State Exchanges and 1 SBE-FP anticipated to be operational in 2027, we estimate a burden of 20,700 hours (23 State Exchanges and SBE-FPs x 900 hours per Exchange) at an annual cost starting in 2027 of $1,560,780 (23 State Exchanges and SBE-FPs x 900 hours per Exchange x $75.40 per hour).

\391\ See Table 14: Adjusted Hourly Wages Used in Burden Estimates.

We sought comment on these proposed burden estimates and assumptions.

We did not receive any comments in response to the proposed burden estimates for this policy. For the reasons outlined in the proposed and final rules, we are finalizing these estimates as proposed.

We are finalizing our proposal to amend Sec. 155.1200(d) to reduce duplication between the proposed SEIPM program described in proposed subpart Q and the annual independent external programmatic audit requirements and standards described at Sec. 155.1200(c) and (d). We are adding Sec. 155.1200(e) to permit a State Exchange to satisfy certain annual independent external programmatic audit requirements, as described at Sec. 155.1200(d), by completing the required annual SEIPM program process finalized in this rule. As a result, we estimate that there would be a general burden reduction for State Exchanges related to the programmatic audit requirement under Sec. 155.1200(c). In

particular, the 22 State Exchanges that operate their own eligibility and enrollment platforms would incur lower costs for contracts with independent external auditors, since many requirements under subparts D and E would be addressed through completion of the SEIPM process for the applicable benefit year.

In the proposed rule, we stated that based on industry estimates of the average cost of contracting an auditor to perform an independent external programmatic audit, we project that the reduced audit scope would lower annual costs by approximately $45,000 for each State Exchange (91 FR 6433). This is based on an estimated average annual programmatic cost of $150,000. We anticipate the total cost annual reduction across 22 State Exchanges would be approximately $990,000 and that these savings could begin as early as 2027, coinciding with the submission of independent external audits for the PY 2026 SMART. However, we also noted that this change would also introduce a new burden associated with completing the SEIPM process, as discussed in the section below.

We sought comment on these proposed burden estimates and assumptions and specifically sought feedback from State Exchanges regarding the annual cost of the programmatic audit process.

We did not receive any comments in response to the proposed burden estimates for this policy. For the reasons outlined in the proposed and final rules, we are finalizing these estimates as proposed.

O. ICRs Regarding the State Exchange Improper Payment Measurement (SEIPM) (Sec. Sec. 155.1600-155.1650)

As described in the preamble to Sec. 155.1600, SEIPM is being finalized as proposed to replace the previous IPPTA program with requirements related to mandatory participation in SEIPM. SEIPM is designed as a process for HHS to review payments of APTC that were determined by State Exchanges to produce an estimate of improper payments.

In the preamble to Sec. 155.1615(a)(1), we are finalizing our proposal that State Exchanges would provide to HHS: the State Exchange's Program Information which consists of policy, operational and technical documentation concerning business rules and calculations, entity relationships, data dictionaries, operating procedures, and system technology. This information is currently retained by State Exchanges in a digital format and can be electronically transmitted to HHS. We estimate that the burden associated with the collection and transfer of this information to HHS would be no more than 40 hours.

In the preamble to Sec. 155.1615(a)(2), we are finalizing our proposal that State Exchanges would provide HHS with the universe of tax household information respective to the plan year being reviewed, that being a listing of the population of tax households that were enrolled in a QHP, where payments of APTC were made. The listing must include an identifier for each tax household, an identifier for each QHP policy within that tax household, the tax household size, the total payment amounts for each sampled unit for the benefit year, and information about the existence of an eligibility verification inconsistency associated with each sampled unit. The burden associated with the finalized collection of information includes the time it would take each State Exchange to meet with HHS to review the submitted information. We estimate that the burden associated with this data collection and transfer would be no more than 40 hours.

In the preamble to Sec. 155.1615(a)(3), we are finalizing our proposal that State Exchanges would provide HHS with review unit data, that being the specific information that is required to review each of the sampled QHP tax household, which includes the following information at the tax household level:

Information pertaining to the calculation of the APTC benefits paid. This includes monthly enrollment premium amounts, monthly APTC payment amounts, monthly Second Lowest Cost Silver Plan Premium amounts, and monthly essential health benefit amounts.

Information provided by policy issuers relevant to enrollment reconciliation. This includes dates and amounts of effectuation payments, APTC and premium payment information, and policy start and end dates.

Information relevant to the determination of eligibility for an SEP (where applicable), this includes consumer attestations and representations, copies of documentary evidence submitted by applicants, electronic verification information, and timing information.

Information about timing of certification and coverage area of the associated QHP. This includes the coverage area of the QHP, timing of QHP certification or approval, and timing of QHP decertification or suppression.

For each person on the policy who is included in the APTC payment calculation:

Attestation and demographic information relevant to initial QHP. This includes the demographic information and consumer attestations and representations.

Information relevant to electronic eligibility verifications and payment determinations. These include the electronic source consulted, the timing of the verification, and the results of the verification.

Information relevant to QHP and APTC manual eligibility verifications and the resolution of electronic verification inconsistencies. This includes copies of documentary evidence submitted by applicants, the timing of submission, the timing of adjudication, and information about good faith extensions.

HHS would specify the manner in which the data is collected. HHS anticipates utilizing a standardized data request form with specific required fields for the collection of this information. The final collection instrument and methodology will be specified in subsequent guidance and would be designed to minimize burden while ensuring data quality and consistency across State Exchanges. HHS will provide State Exchanges with detailed specifications for data formatting, submission procedures, and technical requirements prior to implementation. We estimate that the burden associated with this data collection and transfer would be no more than 8 hours per sample. We anticipate each State Exchange would need to provide between 50 to 250 samples proportionate to the total amount of APTC payments processed by the State Exchange. At the aggregate level, a total sample size of approximately 2,000 tax households would be used to support improper payment measurement across all State Exchanges. In future periods, the total sample size may be adjusted based on factors such as observed error rates, statistical precision requirements, State Exchange participation levels, and available program resources, while ensuring compliance with OMB statistical sampling guidance for improper payment measurement.

The burden associated with completion and return of the required information would be the time it would take each State Exchange to meet with HHS to review the information being requested, analyze and design any database queries needed to produce the information, organize the information into a document or documents for the

purposes of transmittal to HHS, electronically transmit the information to HHS, and meet with HHS to verify and validate the information.

We estimate that for each State Exchange, the total costs would range between $24,950 and $124,750 depending on the identified sample size. The calculation at the low end of the range was produced by multiplying 50 (the smallest number of samples that will be used in SEIPM) x $499 (the average cost per sampled record) = $24,950. The calculation at the high end of the range was produced by multiplying 250 (the largest number of samples that will be used in SEIPM) x $499 = $124,750.

The annual, aggregated burden for the total 22 State Exchanges to complete the SEIPM is estimated to be $1,097,800. This calculation was made by multiplying 2,200 (the total number of samples to be used in SEIPM) x $499 (the average cost per sample). This cost estimate encompasses the processes at the State Exchanges that includes but is not limited to the following: sampling procedures, data collection protocols, and analytical frameworks required to produce an annual improper payment estimate while maintaining statistical validity and regulatory compliance standards.

To compile our estimates, we utilized industry-standard burden estimation methodologies commonly employed for Federal data collection initiatives. We conducted a comprehensive task analysis to identify specific personnel roles and time requirements across all phases of the data collection process, including transition and SEIPM preparation, system setup and maintenance, materials preparation, tool and data preparation for review processes, pre-engagement activities, sampling procedures, review conduct, collaborative observations, and closeout activities. This systematic approach ensures our estimates reflect realistic operational requirements based on established Federal data collection practices.

Hourly wage rates vary across the occupational specialties necessary to perform the information collection and are as follows: [GRAPHIC] [TIFF OMITTED] TR20MY26.036

This establishes a mean hourly rate of $111.12 across all of the occupational specialties that would be needed for performing this collection.

While the initial burden estimate assumes 8 hours per sample as a baseline, HHS recognizes that State Exchanges would realize significant economies of scale when processing multiple samples within the same collection period. The initial sample requires the upfront costs in system setup, query development, staff training, and process establishment. However, subsequent samples within the same collection cycle will benefit from:

Established data extraction processes and validated database queries

Trained personnel familiar with HHS requirements and submission procedures

Streamlined workflows and standardized documentation templates

Reduced coordination overhead through established communication channels

These efficiencies typically reduce the per-sample burden for subsequent samples after the initial setup. The 8-hour baseline represents the maximum expected burden per sample, with actual burden decreasing as State Exchanges leverage established processes and systems for additional samples within the same collection period, equating to an average hourly burden per sample of 4.49 hours.

The calculations in this paragraph demonstrate how the cost estimates were derived for the data collection process across State Exchanges. The mean hourly rate of $111.12 was calculated by averaging the five adjusted median occupational wage rates ($99.00 + $164.62 + $97.30 + $99.80 + $94.88 = $555.60 / 5 = $111.12). While the baseline estimate assumes 8 hours per sample initially, economies of scale reduce the average burden to 4.49 hours per sample as State Exchanges develop efficient processes for subsequent samples. The cost per sample is calculated by multiplying the average burden hours by the mean hourly rate (4.49 hours x $111.12 = approximately $499 per sample). Finally, the aggregate cost estimate of $1,097,800 across all 22 exchanges represents the total expected cost when these efficiencies are realized across the entire sample collection process, which works out to an average of approximately $49,900 per State Exchange, calculated with the premise that each State Exchange would submit on average 100 samples. In summary, the total cost of $1,097,800 is derived from multiplying the estimated average cost per sample ($499) times the total samples (2200) to be drawn across all the State Exchanges.

The costs associated with the SEIPM program will begin in 2027, coinciding with the effective date of the regulation as specified in Sec. 155.1605(a). These are annual recurring costs that State Exchanges will incur each year as part of the ongoing SEIPM requirements. The annual nature of these costs reflects the ongoing data submission processes that State Exchanges must perform to support HHS' annual improper payment measurement and reporting obligations under the Payment Integrity Information Act of 2019.

We will request to account for the associated information collection burden under OMB control number: 0938-NEW/CMS-10942.

Additionally, as described in the preamble to Sec. 155.1535, we are finalizing that State Exchanges may be required to develop and implement corrective action plans (CAPs) following a completed SEIPM measurement designed to reduce improper payments as a result of eligibility determination errors, beginning in 2029. The burden associated with this requirement is the time and effort put forth by State Exchanges to develop and submit a CAP to HHS. We estimate that it would take each selected State Exchange up to 1,000 hours to develop a CAP. We estimate that the total annual burden associated with this requirement for up to 22 State Exchange respondents would be up to 22,000 hours. Assuming the management analyst average hourly rate of $97.30 per hour, we estimate that the cost of a corrective action plan per State Exchange could be up to $97,300, and for all 22 State Exchanges, up to $2,140,600. The burden related to this information collection will be submitted to OMB for approval after future rulemaking has been completed regarding the CAP process and requirements.

We sought comment on these proposed burden estimates and assumptions.

After consideration of comments and for the reasons outlined in the proposed rule and this final rule, including our responses to comments, we are finalizing these burden estimates for this policy as proposed. We summarize and respond to public comments received on the proposed estimates below.

Comment: Several commenters stated concerns regarding the burden calculations associated with SEIPM. Most of these concerns pertained the anticipated increased cost for resources needed for the data processing and the manual effort needed for documentary evidence requirements. Some commenters shared specific burden calculations associated with IPPTA and stated that SEIPM burden will be significantly more. One commenter stated that HHS did not account for the hours and costs for State Exchanges to make modifications in the PRA estimations or the current ICR of the Proposed Rule. One commenter noted that the IPPTA work accounted for at least 400 staff hours to date. Other commenters stated that HHS underestimated the burden calculations due to the complexity and challenges experienced in IPPTA, which may transfer to SEIPM. Other commenters requested additional details on the sampling methodology, sample size estimates, and other information to accurately estimate State Exchange burden and costs associated with SEIPM.

Response: We conducted a comprehensive analysis to identify specific personnel roles and time requirements across all phases of the data collection process, including transition and SEIPM preparation, system setup and maintenance, materials preparation, tool and data preparation for review processes, pre-engagement activities, sampling procedures, review conduct, collaborative observations, and closeout activities. We used the GSA labor category table to estimate burden on key occupational roles that we considered crucial in SEIPM while also using some of the early survey data provided by State Exchanges in Group A, although we received limited feedback centered on the burden concerns. While we received some IPPTA burden information from a couple of commenters, we did not receive information across all State Exchanges.

While some commenters stated that significant time and resources were required for IPPTA, we understand that there is variability across each state in terms of how much time and resources are required. The processes such as developing SQL scripts that were completed during IPPTA are intended to translate into the SEIPM process. The time and resources spent for developing those scripts and troubleshooting the output would not be experienced in SEIPM because the work will already have been completed. We clarify that we will allow flexibility in the data submission process to alleviate some of the administrative burden placed on the State Exchanges. We also intend to release sub-regulatory guidance to provide further details on SEIPM. For these reasons, HHS believes that the proposed estimations are sufficient for the State Exchanges to complete SEIPM.

Comment: Many commenters stated concerns about SEIPM being duplicative of other audits such as the independent external programmatic audit.

Response: We note that we have addressed duplication concerns in the General Program Integrity and Oversight Requirements of this final rule under Sec. 155.1200 and SEIPM under Sec. 155.1645. We also clarify that we intend to release sub-regulatory guidance to provide additional clarity.

P. ICRs Regarding the Discontinuation of Standardized Plan Options (Sec. Sec. 155.20, 155.205(b)(1), 155.220(c)(3)(i)(H), 156.201, and 156.265(b)(3)(iv))

We are finalizing our proposal to remove the following from our regulations effective beginning in PY 2027: the definition of “standardized options” at Sec. 155.20; all requirements pertaining to standardized plan options at Sec. 156.201 (the requirements for FFE and SBE-FP QHP issuers in the individual market to offer these plans at paragraphs (a) and (b) as well as the requirement for these plans to meaningfully differ from one another at paragraph (c)); the differential display of standardized plan options on HealthCare.gov at Sec. 155.205(b)(1); and the corresponding standardized plan option differential display requirements for approved web-broker and QHP issuer enrollment partners using a DE pathway to facilitate consumer enrollment through an FFE or SBE-FP at Sec. Sec. 155.220(c)(3)(i)(H) and 156.265(b)(3)(iv).

As stated in the proposed rule (91 FR 6435), under Sec. Sec. 155.220(c)(3)(i)(H) and 156.265(b)(3)(iv), approved web-brokers and QHP issuers using a DE pathway to facilitate enrollment through an FFE or SBE-FP must differentially display standardized plan options in accordance with Sec. 155.205(b)(1) in a manner consistent with how standardized plan options are displayed on HealthCare.gov, unless we approve a deviation. Any requests from web-brokers and QHP issuers seeking approval of an alternate differentiation format are reviewed based on whether the same or a similar level of differentiation and clarity is provided under the requested deviation as is provided on HealthCare.gov.

The current information collection is Non-Exchange Entities (OMB Control Number: 0938-1329 (CMS-10666)/Expiration date: February 20, 2029). Given that we are finalizing our proposal to discontinue the full suite of standardized plan option policies from our regulations (including standardized plan option differential display requirements for approved web-broker and QHP issuer enrollment partners using a DE pathway to facilitate consumer enrollment through an FFE or SBE-FP at Sec. Sec. 155.220(c)(3)(i)(H) and 156.265(b)(3)(iv)), we are also finalizing the discontinuation of this information collection--as these entities are no longer required to submit a request to deviate from the form of display on HealthCare.gov.

We sought comment on the proposal to discontinue this information collection. We did not receive any comments in response to the proposal to discontinue this information collection. For the reasons outlined in the proposed and final rules, we are finalizing the discontinuation of this information collection as proposed.

We are finalizing our proposal at Sec. 155.1050(d), for PY 2027 and beyond, to allow FFE States, including States that perform plan management, that elect to do so, to conduct provider access reviews for issuers' plans that use and do not use a provider network, provided that the State has demonstrated sufficient authority and the technical capacity to conduct such reviews by satisfying the applicable criteria to be considered to have an Effective Provider Access Review Program, as described at Sec. 155.1050(d)(2) through (d)(4) as finalized in this rule. We will continue to conduct provider access reviews consistent with Sec. 156.230 for QHP issuers that use a provider network and Sec. 156.230 for QHP issuers that do not use a provider network in FFE States that do not elect to conduct such reviews, or in FFE States that do not demonstrate sufficient authority and the technical capacity to conduct such reviews by satisfying the applicable criteria to be considered to have an Effective Provider Access Review Program, as described at Sec. 155.1050(d)(2) through (d)(4) as finalized in this rule. Under this finalized policy, we will continue to collect network adequacy data, including time and distance and appointment wait time data. We will continue collecting this data from all FFE issuers, either to use to conduct Federal network adequacy reviews in FFE States that do not elect to do so, or do not demonstrate they have sufficient authority and the technical capacity to conduct these reviews by satisfying the applicable criteria to be considered to have an Effective Provider Access Review Program as described at Sec. 155.1050(d)(2) through (d)(4), or with a view to make it available in a standardized format to States that are determined to have an Effective Provider Access Review Program, to assist them in their provider access analysis. We stated in the proposed rule (91 FR 6436) that we do not believe this proposal would introduce new burdens associated with data collection, as we would continue to utilize the same systems, processes, and data requirements currently in place. We believe the ICRs associated with this finalized policy are assessed and are encompassed by the revised information collections for QHP certification and network adequacy data collection (Continuation of Data Collection to Support QHP Certification and other Financial Management and Exchange Operations (OMB Control Number 0938-1187 (CMS- 10433)/Expiration date: June 30, 2025) and Essential Community Provider-Network Adequacy (ECP/NA) Data Collection to Support QHP Certification (OMB Control Number. 0938-1415 (CMS-10803)/Expiration date: December 31, 2027)). Overall, we expect any change in burden cost to be negligible under this finalized policy. We do expect the total burden cost associated with the provider access review process to decrease for QHP issuers in States with an Effective Provider Access Review Program, as outside of initial data submission and validation, these issuers would not be subject to review processes conducted by HHS. However, burden costs saved by QHP issuers on the Federal level may be lost at the State review level, depending on how a State implements provider access review processes. It is unknown how States will implement provider access data collection and certification reviews under this final policy and the number of States that will elect to conduct these reviews, thus the total burden associated with undergoing this provider access certification review process on the State-level is uncertain.

We sought comment on these proposed burden estimates and assumptions.

We did not receive any comments in response to the proposed burden estimates for this policy. For the reasons outlined in the proposed and final rules, we are finalizing these estimates as proposed.

In this final rule, we are not finalizing our proposal to reduce the minimum percentage requirements described under Sec. 156.235(a)(2)(i) and (b)(2)(i) from 35 to 20 percent for the overall, FQHC, and family planning ECP thresholds, and will maintain the minimum percentage at 35 percent for each of the three aforementioned thresholds. We are finalizing our proposal to amend the narrative justification requirement language at Sec. 156.235(a)(3) and 156.235(b)(3) to reflect current operations and data submission requirements as part of ECP certification reviews, as narrative justifications are no longer required for issuers not meeting the ECP standard because they input contract statuses directly into the ECP User Interface in the MPMS. Additionally, we are finalizing our proposal, with modification, to allow FFE States flexibility to elect to conduct ECP certification reviews. Specifically, as discussed in the preamble of this final rule, we are finalizing our proposal to allow FFE States flexibility to elect to conduct ECP certification reviews for network plans effective beginning PY 2027; however, we are modifying our proposal such that we will allow FFE States to conduct ECP certification reviews for non-network plans effective beginning PY 2028 under Sec. 155.1051 due to the delayed implementation of the provisions allowing certification of non-network plans as QHPs. As noted in the proposed rule, the ICRs associated with QHP certification and ECP Data Collection to Support QHP Certification have already been assessed and are encompassed by the currently approved information collections (Continuation of Data Collection to Support QHP Certification and other Financial Management and Exchange Operations (OMB Control Number 0938-1187 (CMS-10433)/Expiration date: June 30, 2025) and Essential Community Provider/Network Adequacy (ECP/NA) Data Collection to Support QHP Certification (OMB Control Number. 0938-1415 (CMS-10803)/Expiration date: December 31, 2027)) (91 FR 6436).

We note that the type of ECP data collected from issuers will remain the same; issuers will still be required to designate contracted ECPs included within their provider networks for each of their service areas to meet the ECP standard under Sec. 156.235. Thus, we expect issuer burden to remain at least the same by maintaining existing ECP threshold requirements, or lower due to recent system enhancements within the ECP UI in MPMS that aim to minimize issuer burden. For example, MPMS system enhancements within the ECP UI include optimized filter options that display applicable ECPs relevant to meeting specific ECP requirements (including threshold requirements) if selected as contract executed or contract offered by issuers; prior year import functionality that enable issuers to import ECP data from their previous year's QHP application, including contracts executed with ECPs, which reduces time needed to re-enter details that are up to date; and an ECP calculation workspace that provides direct feedback on how issuers scored on each ECP requirement within each network and service area (for example, a met versus unmet status), and how many additional ECPs need to be included within their application to satisfy ECP requirements. However, issuers may not experience reductions in administrative costs due to the need to maintain existing contracts, including by re-negotiating contract renewals and/or pursuing additional contracts to continue to meet existing ECP requirements.

Based on an analysis of PY 2026 FFE plan data, the average threshold percentage for all FFE QHP issuers, including issuers in States performing plan management, was 71 percent for the overall ECP threshold requirement, 85 percent for the family planning provider threshold requirement, and 79 percent for the FQHC threshold requirement. Thus, many issuers continue to exceed current threshold requirements by more than 30 percent, so even if the threshold were reduced to 20 percent, the reduction may not have influenced issuer contracting behavior and associated administrative cost savings. Therefore, in this final rule, we are not finalizing our proposal to reduce the minimum percentage requirements, which will maintain the minimum percentage at 35 percent for the overall, FQHC, and family planning ECP thresholds.

Furthermore, according to an analysis of PY 2025 FFE plan data, 14 medical QHPs (including one dual QHP) and 8 additional SADPs would have been required to submit narrative justifications for not meeting the ECP standard under Sec. 156.235 if these data requirement collections were still in place. In the justification Excel format used prior to PY 2025, the 22 issuers referenced previously would have spent on average an estimated minimum of at least 2 minutes per ECP inputting provider contact information and the status of negotiations. The modernizations to the ECP data collection process in the ECP UI implemented beginning for PY 2025 have contributed to burden reductions among these issuers, since the time spent reporting provider data will be reduced, with issuers easily importing their prior year's ECP data into their current year's application or selecting ECPs with pre-populated contact information from the list embedded in MPMS. Additionally, in lieu of providing information on particular ECPs and writing responses to questions pertaining to monitoring and mitigating measures for ECP network gaps in the Excel justification format, these issuers now designate the status of negotiations with particular ECPs by selecting from a drop-down list in MPMS, which averages an estimated minimum of at least 5 seconds per ECP. As a whole, these efficiencies to the justification process through the ECP UI MPMS modernizations have reduced issuer burden as part of ECP certification reviews through reductions in the amount of time issuers spend submitting ECP data because the data is mostly prepopulated within MPMS, there are drop- down options to quickly append the status of contract negotiations, and MPMS clearly identifies needed corrections and required fields for the issuer to complete a satisfactory justification to support their QHP certification. Therefore, we are finalizing our proposal to change the narrative justification regulation text at Sec. 156.235(a)(3) and (b)(3) to be consistent with these system changes, current HHS operational processes, and existing issuer ECP data submission requirements as part of ECP certification reviews.

In addition, we are finalizing our proposal, with a minor modification, to allow FFE States, including States performing plan management, to elect to conduct their own ECP certification reviews of issuers plans' with or without a provider network provided the State demonstrates it has sufficient authority and the technical capacity to conduct these reviews by meeting the applicable criteria, as determined by HHS, to be considered to have an Effective ECP Review Program under Sec. 155.1051. While we are finalizing, beginning PY 2027, the proposal for FFE States to conduct their own ECP certification reviews of issuers' plans with a provider network provided the State demonstrates it has sufficient authority and the technical capacity to conduct these reviews, we are modifying our proposal to delay application of this policy to ECP certification reviews of issuers' non-network plans until PY 2028 due to the delayed implementation of the provisions allowing QHP certification of non-network plans. An FFE State will need to first express its interest to HHS and submit an attestation, and it will be granted an Effective ECP Review Program designation after HHS determines it meets all applicable requirements described for this program under Sec. 155.1051. An FFE must also demonstrate sufficient authority and technical capacity to review non- network plans seeking QHP certification beginning PY 2028, if the State deems to allow such plans to operate in the State. If we determine that an FFE State does not have an Effective ECP Review Program or an FFE State does not elect to conduct such reviews, then we will continue to perform ECP certification reviews consistent with Sec. 156.235 for network plans and Sec. 156.236 for non-network plans (effective PY 2028). We are revising the information collection currently approved under OMB Control Number 0938-1415 (CMS-10803) (Essential Community Provider-Network Adequacy (ECP/NA) Data Collection to Support QHP Certification to reflect new requirements finalized under Sec. 155.1051 for the Effective ECP Review Program. Since we will perform ECP certification reviews for issuers in FFE States without an Effective ECP Review Program consistent with our current operations, processes, and data submission requirements as part of QHP certification, we do not believe this finalized policy will introduce any new burdens associated with data collection. In addition, for QHP issuers in Effective ECP Review Program States, we do expect the total annual hours and annual burden cost associated with the ECP certification review process to slightly decrease on the Federal level. While QHP issuers in FFE States with an Effective ECP Review Program will still need to submit ECP data to HHS, issuers will not be required to undergo the extensive ECP review process to address corrections identified by HHS by resubmitting data, if they instead go through this process in FFE States with an Effective ECP Review Program. However, burden costs saved by QHP

issuers by not undergoing the extensive ECP certification review process on the Federal level may be offset at the State level if FFE States impose new, additional ECP certification data collection and review procedures for QHP issuers that do not already exist to comply with Sec. 155.1051. It is unknown how FFE States will implement ECP data collection and certification reviews and the number of FFE States that will elect to conduct these reviews, thus the total burden associated with undergoing this ECP certification review process on the State level is uncertain.

We sought comment on these proposed burden estimates and assumptions, but we did not receive any comments in response to these proposed burden estimates related to ECP standards for network plans (Sec. 156.235) and the implementation of the proposed Effective ECP Review Program (Sec. 155.1051).

T. ICRs Regarding QHP Certification of Non-Network Plans (Sec. Sec. 155.1050, 156.230, 156.235, 156.236, 156.275, and 156.810)

In this final rule, we are finalizing a number of revisions to Part 155 and Part 156 to allow plans that do not use a network (non-network plans) to receive QHP certification beginning with PY 2028 by demonstrating that they ensure a sufficient choice of providers in a manner consistent with section 1311(c)(1)(B) and (C) of the Affordable Care Act. We are finalizing our proposal to add new section Sec. 156.236, that contains the provider access sufficiency standards (including ECP access) specific to non-network plans, and to revise Sec. Sec. 156.230 and 156.235 to make clear that those sections address the provider access sufficiency standards (including ECP access) for network plans. Additionally, we clarify that non-network plans would be subject to and must be able to meet all of the general certification criteria at Sec. 155.1000(c), which would allow Exchanges the ability to certify non-network plans as QHPs. Furthermore, we are finalizing our proposal effective beginning in PY 2028 to allow FFE States, including States performing plan management, to conduct provider access and/or ECP certification reviews provided the State elects to conduct these reviews and demonstrates it has sufficient authority and the technical capacity to conduct these reviews by meeting the applicable criteria, as determined by HHS, for each review program it wishes to administer; these review programs include the Effective Provider Access Review Program for provider access certification reviews under Sec. 155.1050(d) and/or the Effective ECP Review Program for ECP certification reviews under Sec. 155.1051. Accordingly, FFE States that elect to conduct provider access certification reviews, and are determined by HHS to have sufficient authority and the technical capacity to conduct these reviews by satisfying applicable criteria to be considered to have an Effective Provider Access Review Program under Sec. 155.1050(d)(2) through (d)(4) will be permitted to perform such reviews of non-network plans, effective for non-network plans seeking QHP certification beginning PY 2028. Similarly, FFE States that elect to conduct ECP certification reviews, and are determined by HHS to have sufficient authority and the technical capacity to conduct these reviews by meeting applicable criteria to be considered to have an Effective ECP Review Program under Sec. 155.1051 will be permitted to perform such reviews of non-network plans seeking QHP certification beginning PY 2028. The revision of the information collection currently approved under OMB Control Number 0938-1415 (CMS-10803) (Essential Community Provider-Network Adequacy (ECP/NA) Data Collection to Support QHP Certification) to reflect the finalized requirements under Sec. 156.236 for non-network plans will be revised separately at a later date for OMB review and approval through the PRA renewal package process.

We believe that most of the current provider access data collection and submission requirements that apply to network plans would also apply to provider access reviews for non-network plans. Relevant to provider access reviews, under Sec. 156.236(b)(1), non-network plans will be required to report their assessed percentage of providers in a service area that accept the plan's benefit amount as payment in full.

Additionally, to comply with Sec. 156.236(b)(4) through (9), non- network plans will be required to submit supporting documentation and explain how they meet these regulatory requirements. Non-network plans will be required: to describe the processes and/or methodologies in place to conduct continuous outreach to available providers in a particular service area to determine whether they would accept the plan's benefit amount as payment in full; to identify how they make benefit amounts publicly available and accessible; to explain how benefit amounts are determined; to detail how they provide consumer- friendly and public information about potential balance billing scenarios and expected out-of-pocket costs; to validate that they offer an exceptions process for enrollees who cannot find providers (including ECPs) willing to accept the benefit amount as payment in full; and summarize how they provide adequate customer service or online provider directory assistance resources to assist plan enrollees and potential enrollees in finding providers (including ECPs) in their area who will accept the plan's benefit amount as payment in full. It is uncertain approximately how many non-network plans will apply for QHP certification beginning PY 2028 to reasonably estimate the total annual burden cost and hours for completing these requirements. However, we expect the time for responding to questions to assess compliance with Sec. 156.236(b)(4) through (9) and submitting supporting documentation for a single non-network plan will range between 20 to 40 minutes for each of the 6 attestation questions, if assuming a 500-word limit, likely requiring a maximum 2 to 4 hours total to complete.

Furthermore, we believe that many of the current ECP data collection and submission requirements that already apply to network plans would also apply to non-network plans. First, non-network plans applying for QHP certification would similarly use MPMS, which has extensively streamlined data collection and submission, reducing burden among issuers during QHP certification. The MPMS ECP UI only displays qualified and eligible ECPs in the issuer's State, reducing the burden of filtering through the entire ECP List for applicable facilities. Instead of spending time and effort inputting individual ECP data (such as facility name, facility address, ECP reference number, NPI, etc.) for each applicable facility in each of the plan's applicable network and/or service area, QHP issuers, including SADPs, are able to use MPMS to select prepopulated ECPs from a list of available and eligible ECPs within the user interface. MPMS is also updated regularly during QHP certification to remove ECPs that have closed or are no longer eligible such that issuers do not spend time entering in ECP data that is no longer valid or applicable to their QHP application.

Non-network plans must submit ECP data in MPMS to demonstrate they meet ECP related requirements at Sec. 156.236(b)(1) through (3) such as: whether the non-network plan meets at least a minimum percentage, as specified by HHS, of available ECPs that accept the plan's benefit amount as payment in full in each plan's service area collectively across all ECP categories defined under Sec. 156.235(a)(2)(ii)(B), and at least a minimum percentage of available ECPs

in each plan's service area within certain individual ECP categories, as specified by HHS; whether the non-network plan offers the benefit amount as payment in full to at least one ECP in each of the eight ECP categories per county in the plan's service area described in Sec. 156.235(a)(2)(ii)(B); and whether the non-network plan offers the benefit amount as payment in full to all available Indian health care providers in the plan's service area. Network plans currently satisfy data collection requirements by designating contract statuses, including whether a contract was offered or fully executed, with select ECPs within their application in MPMS. To satisfy Sec. 156.236(b)(1) through (3), non-network plans will submit ECP data by similarly selecting ECPs within their application in MPMS, but instead of contract statuses, they will select modified statuses describing whether a select ECP was offered or accepted their benefit amount as payment in full. Thus, we do not believe the finalized ECP requirements under Sec. 156.236(b)(1) through (3) for non-network plans would impose significantly new, additional information collections. Thus, we believe both total annual burden hours and cost of the new ECP requirements under finalized Sec. 156.236(b)(1) through (3) would be negligible.

In summary, we will be revising the information collection currently approved under OMB Control Number 0938-1415 (CMS-10803) (Essential Community Provider-Network Adequacy (ECP/NA) Data Collection to Support QHP Certification) to reflect finalized requirements under Sec. 156.236 for non-network plans at a later time through the OMB review and approval process for PRA renewal packages.

We sought comment on these proposed burden estimates and assumptions. However, we did not receive any direct comments in response to these proposed burden estimates for this policy, thus we are finalizing these estimates. As discussed in III.E.12. of this final rule, we are delaying the implementation of this finalized policy to PY 2028.

This final rule includes payment parameters and provisions related to the HHS-operated risk adjustment and HHS-RADV programs, as well as 2027 benefit year user fee rates for issuers that participate in the HHS-operated risk adjustment program and the 2027 benefit year user fee rates for issuers offering QHPs through FFEs and SBE-FPs. This final rule also includes finalized revisions to the defrayal policy; removal of the requirement for a State to operate a SBE-FP before operation of a State Exchange; expanded

marketing prohibition regulations and mandated use of the HHS-approved and created form for agents, brokers, and web-brokers; strengthened ability to take administrative actions against agents, brokers, and web-brokers; coordination of the new SEIPM process with existing independent external programmatic audit requirements; a prohibition on issuers from including routine non-pediatric dental services as an EHB; cost-sharing changes for catastrophic and bronze plans; clarifications for how catastrophic plans may have plan terms of up to 10 consecutive years; repeal of standardized plan options and non-standardized plan options limits and exceptions; revisions to network adequacy reviews; participation by QHPs that do not use a provider network; Essential Community Provider (ECP) standards and implementation of an Effective ECP Review Program; modification to allow QHP issuers to submit any two of five QISs topic areas listed in section 1311(g)(1) of the Affordable Care Act; imposition of CMPs against issuers in State Exchanges or SBE- FPs; revisions to rate filing justifications; changes to options for implementing premium payment thresholds; and income verification requirements. Finally, this final rule includes updates needed to align Exchange regulations with the WFTC legislation.

We have examined the impacts of this final rule as required by Executive Order 12866, “Regulatory Planning and Review”; Executive Order 13132, “Federalism”; Executive Order 13563, “Improving Regulation and Regulatory Review”; Executive Order 14192, “Unleashing Prosperity Through Deregulation”; the Regulatory Flexibility Act (RFA) (Pub. L. 96-354); section 1102(b) of the Social Security Act; and section 202 of the Unfunded Mandates Reform Act of 1995 (Pub. L. 104- 4); and the Congressional Review Act (5 U.S.C. 804(2)).

Executive Orders 12866 and 13563 direct agencies to assess all costs and benefits of available regulatory alternatives and, if regulation is necessary, to select those regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety, and other advantages; distributive impacts). Section 3(f) of Executive Order 12866 defines a “significant regulatory action” as any regulatory action that is likely to result in a rule that may: (1) have an annual effect on the economy of $100 million or more or adversely affect in a material way the economy, a sector of the economy, productivity, competition, jobs, the environment, public health or safety, or State, local, territorial, or Tribal governments or communities; (2) create a serious inconsistency or otherwise interfere with an action taken or planned by another agency; (3) materially alter the budgetary impacts of entitlements, grants, user fees, or loan programs or the rights and obligations of recipients thereof; or (4) raise novel legal or policy issues arising out of legal mandates, or the President's priorities.

A regulatory impact analysis (RIA) was prepared for this final rule in keeping with Executive Order 12866. Based on our estimates, the Office of Management and Budget's (OMB) Office of Information and Regulatory Affairs (OIRA) has determined that this rulemaking is “significant” per section 3(f)(1). Under Subtitle E of the Small Business Regulatory Enforcement Fairness Act of 1996 (also known as the Congressional Review Act), OIRA has also determined that this is a major rule as defined by 5 U.S.C. 804(2).

We have prepared an RIA that, to the best of our ability, presents the costs and benefits of the rulemaking.