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

In the 2025 Marketplace Integrity and Affordability final rule (90 FR 27074), we finalized the removal of the restriction for Exchanges on the Federal platform to only conduct Special Enrollment Period Verification (SEPV) for Loss of Minimum Essential Coverage (MEC) cat Sec. 155.420(g). This allowed the Federal Exchange to conduct SEPV for additional SEPs. We also finalized a regulation that required Exchanges on the Federal platform to conduct SEPV for at least 75 percent of new enrollments. The final rule included a provision that both of these provisions were set to sunset on December 31, 2026.

In the 2027 Payment Notice proposed rule (91 FR 6352), we reproposed these provisions as their implementation was stayed by the Court in City of Columbus et al. v. Kennedy et al. on August 22, 2025.\178\ In reproposing these provisions following the Court's stay, we stated that this proposal reflects changes in circumstances and new supporting information since the original policy was established. This includes the passage of the WFTC legislation and additional insights from the resumption of SEPV for Loss of Minimum Essential Coverage (MEC) that occurred on May 16, 2025 in compliance with current SEP in verification regulations at Sec. 155.420(g) for Exchanges on the Federal platform. Our proposal for the two SEPV policies did not include a sunset provision.

\178\ City of Columbus v. Kennedy, 796 F. Supp. 3d at 160.

We included the sunset provision in the 2025 Marketplace Integrity and Affordability final rule because we recognized that the then- imminent program integrity concerns were being driven by the existence of fully-subsidized plans. We noted that the expiration of the enhanced subsidies coupled with the temporary program integrity requirements enacted by the rule would right-size Exchange enrollment in PY 2026 and would obviate the need for ongoing higher levels of program integrity policies. We stated that as the excess levels of improper enrollments are reduced in PY 2026, we expected the lower subsidy levels to appropriately deter future levels of improper enrollments from ever growing so high again, diminishing the returns of the temporary policies we are enacting in the rule. In other words, the burden of continuing such policies would have reached a point at which they would outweigh any benefits.

In the proposed rule, we stated that we now believe reproposing these policies (without a sunset) is necessary to ensure integrity in the Exchanges and help limit fraudulent enrollments. The proposal to require Exchanges on the Federal platform to conduct SEPV for the loss of MEC SEP is a return to a previous policy that was implemented pursuant to the 2017 Marketplace Stabilization rule. The SEP verification policy in the 2017 rule was driven in part by a 2016 GAO undercover test study of SEPs. The study observed that self-attestation could allow applicants to obtain subsidized coverage they would otherwise not qualify for and then found 9 out of 12 of GAO's fictitious applicants were approved for coverage on the Federal and selected State Exchanges.\179\ As a result, we implemented verification for the largest SEPs on the Federal Exchange.

\179\ GAO. (2016 Nov.). Patient Protection and Affordable Care Act: Results of Enrollment Testing for the 2016 Special Enrollment Period, GAO-17-78. https://www.gao.gov/products/gao-17-78.

Once SEPV was implemented, we studied how the consumer experience was impacted. For PY 2017, a report showed that we averaged a response time of 1-to-3 days to review consumer-submitted documents. In addition, the vast majority (over 90 percent) of SEP applicants who made a plan selection and were required to submit documents to complete enrollment were able to successfully verify their eligibility for the SEP. We conducted additional research for the following plan years through 2021. Based on data from PY 2019, the last year prior to the COVID-19 PHE, which greatly impacted SEPV processing, the majority of consumers (73 percent) were able to submit documents within 14 days of their SEP verification issue (SVI) being generated. Also, we found that the majority of consumers (63 percent) were able to fully resolve their SVI within 14 days of it being generated. That resolution percentage increased to 86 percent by 30 days.\180\ We also found that for PY 2019, only approximately 14 percent or 75,500 individuals were unable to resolve their SVI out of the total population of SEP consumers who received an SVI. We stated in the proposed rule that the data shows that the value of SEPV processing and the program integrity benefits it provides to the Exchanges is greater than the minimal burdens those same processes place on individuals.

\180\ More consumers resolve passed 30 days due to extensions that they are eligible to receive.

We proposed the 75 percent verification threshold for new SEP enrollments because we believe that most Exchanges would be able to meet it by verifying at least two or three of their largest SEP types based on current SEP volumes. The determination of how many enrollments would constitute 75 percent would be required to be based

on enrollment through all SEPs in the prior plan year. We stated that this would provide Exchanges with implementation flexibility so they can continue to decide which special enrollment types to verify and the best way to conduct that verification. We did not propose to require Exchanges to verify eligibility for all SEPs, because we have determined that the cost to verify eligibility for SEPs with very low utilization rates could be greater than the benefit of verifying eligibility for them.

We stated in the proposed rule that for SEPs that are being verified, the Exchange would “pend” the consumer's enrollment, meaning that it would not be effectuated until the Exchange verified eligibility for enrollment through the SEP. If the Exchange is unable to verify such eligibility, we stated that the consumer would not be eligible for enrollment through the Exchange under that SEP, and any plan selection under that SEP would be canceled (meaning, terminated before coverage is effectuated) and would not result in enrollment.

Verification for the loss of MEC SEP, which is required under Sec. 155.420(g), was paused through the Covid-19 PHE to ensure consumers could maintain access to continuous coverage. This pause in verification ended on May 16, 2025. After resuming verification for the Loss of MEC SEP on May 16, 2025, we noticed shifts in enrollment trends begin to occur.\181\ Prior to the resumption of verification, in April of 2025, the Loss of MEC SEP accounted for approximately 330,000 SEP enrollments which was 48 percent of all SEP enrollments at that time in Exchanges that use the Federal platform. As of September 2025, the Loss of MEC SEP accounted for 95,000 SEP enrollments, which was down to 27 percent of all SEP enrollments at that time.\182\ We also noticed during this same period that several other SEP types had their overall percentage of SEP enrollments increase quite substantially. For example, the Move SEP went from 1 percent to 21 percent of all SEPs, and the Medicaid/CHIP Denial SEP increased from 8 percent to 24 percent of all SEP enrollments. We stated in the proposed rule that this data suggests that consumers shifted their SEP attestation so as not to have to provide verification of eligibility for the SEP.

\181\ We note that it is too soon for CMS to observe these trends as of the date the Program Integrity final rule was published on June 25, 2025.

\182\ These numbers are derived from internal FFE SEP enrollment data.

We acknowledged in the proposed rule that some shift in SEP volumes was expected due to our best SEP logic, which is a set of hierarchy rules that Exchanges on the Federal platform use to determine what the “best SEP” is for a consumer (generally based on the most advantageous coverage effective date for the qualifying life event experienced by the consumer, verifiable with documents as required), in the event that they attest to multiple SEP qualifying events, such as losing MEC, while also gaining a dependent. Essentially, consumers are often eligible for more than one SEP type and, once verification resumed, another SEP type may become the best SEP for a consumer. However, the substantial shift cannot be explained by that logic alone as these trends do not match any of our historical SEP enrollment data.

When SEPV was first implemented in 2017 and 2018, we noticed shifts in SEP enrollment patterns that resulted in non-verified SEPs making up a larger portion of the total SEP population. For example, the overall portion of consumers granted a non-verified SEP that made them eligible for the Exchange increased from 2.5 percent in 2017 to 10 percent in 2018. During that same period, the Loss of MEC SEP decreased from 60 percent of all SEPs in 2017 to 54 percent in 2018, and the Medicaid/ CHIP Denial SEP decreased from 24 percent in 2017 to 19 percent of all SEPs in 2018. From 2019 to 2024, although SEP enrollment volume increased drastically, the proportion of enrollment though each SEP stayed relatively similar. The introduction of the under 150 percent FPL SEP did result in the volume of other non-verified SEPs decreasing. The only notable changes were that the total portion of loss of MEC SEPs increased 5 percent and Medicaid/CHIP denial decreased 6 percent. Given the mass shift away from the loss of MEC SEP throughout 2025 and the significant growth in non-verified SEPs during the same time frame, we stated in the proposed rule that we believe there is a high likelihood action is being taken to intentionally avoid SEP verification. We stated that we believe this trend is being driven primarily by agent and broker activity as 86 percent of SEP enrollments are through agents and brokers.

In addition to trying to mitigate the concern that individuals are attesting to SEPs they are not eligible for in order to avoid verification, we stated in the proposed rule that we believe SEP verification would also help deter bad actors and those who are ineligible to enroll in coverage from gaining access to the Exchanges. We stated that we believe that this would help to reduce rates by preventing individuals who are waiting until they are sick to enroll from utilizing SEPs for which they may be ineligible. As we explained in the 2025 Marketplace Integrity and Affordability rule, we believe that continued access to zero-dollar bronze plans increases the risk of fraudulent enrollments and ineligible individuals gaining access to coverage through SEPs that do not require verification. We believe that increased SEP verification, as we stated in that rule, would reduce the risk of fraud and ineligible enrollments related to zero-dollar bronze plans in the FFE.

For the reasons provided above, we reproposed without a sunset at Sec. 155.420(g), the provision to remove the restriction for Exchanges on the Federal platform to only conduct SEPV for Loss of MEC, and the provision to require Exchanges on the Federal platform to conduct SEPV for at least 75 percent of new enrollments.

We sought comment on this proposal.

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 this policy as proposed. We summarize and respond to public comments received on the proposal to resume Special Enrollment Period Verification.

Comment: Several commenters stated concerns regarding how the proposed policy would apply given City of Columbus v. Kennedy litigation.

Response: Though SEPV provisions finalized in the 2025 Marketplace Integrity and Affordability rule were stayed in City of Columbus v. Kennedy, SEPV was originally enacted with the publication of the 2017 Market Stabilization Rules as a program integrity tool to reduce the incidence of consumers who use an SEP to enroll in coverage when they are not eligible to do so, which caused significant instability to the risk pools and increased the financial burden on issuers. We are finalizing the proposal to resume SEPV to address similar program integrity concerns identified in the 2017 Market Stabilization Rules, but with the added goal of preventing consumers from being subject to unauthorized enrollment and unauthorized plan switches. Specifically, When SEPV was initially implemented, the goal was to reduce the immediate burden on risk pools caused by consumers using an SEP for which they were not eligible to enroll into coverage only when they needed medical care. This current proposal is intended to similarly to protect the risk

pool from adverse selection and to reduce the incidence of unauthorized enrollment and unauthorized plan switches which can more easily be accomplished when an applicant does not have to verify that they are eligible for a SEP (other than provide an attestation).

Comment: Some commenters stated concern with the perceived increased administrative burden on State Based Exchanges, agents and brokers, as well as consumers. They point to large upfront costs to a State Exchange to develop verification infrastructure, increase time burden on agents and brokers in assisting consumers with submitting documents, and the difficulty that some consumers might experience with locating and requesting documents to resolve their SVI.

Response: Commenters on the 2025 Marketplace Integrity and Affordability Rule estimated that the initial cost per State Exchange to develop their own verification infrastructure would be $12 to 60 million. While we recognize that these estimated operational costs may be significant, commenters did not address the ongoing impact that adverse selection and improper enrollments may have on the program and consumers. To mitigate the operational impact on SBEs, we proposed, and are finalizing a requirement that they verify only 75 percent of SEP enrollments.

Agents, brokers, and web-brokers currently have access to training and resources that detail the SEP verification process and the documents required to resolve each SVI, therefore, we do not believe that SEPV will increase time burden on agents and brokers in assisting consumers with submitting documents. Additionally, the documentation required to resolve SVIs does not represent a wholly new type of administrative burden for consumers, as consumers may already encounter documentation submission requirements in connection with other eligibility and verification processes.

For example, under a Loss of MEC SEP, which is one of the most commonly utilized SEPs, consumers who lose employer-sponsored coverage may receive documentation from their employer that they could provide to the Exchange to demonstrate eligibility for the SEP. Accordingly, while we recognize that SEPV may impose administrative burden on agents, brokers, web-brokers, and consumers, we do not believe that such burden is unreasonable in light of the program integrity and consumer protection benefits associated with SEPV.

Comment: Some commenters noted that SEPs in general are underutilized, that self-attestations are sufficient to demonstrate eligibility for most SEPs, that monthly SEPs should be allowed to provide consumers with more flexibility, and that CMS should be working to make enrollment easier, not more difficult. Some commenters suggested that CMS should make a single-button reenrollment option to streamline the reenrollment process for consumers, accept “reliable” self-attestations to justify SEP eligibility, and provide temporary eligibility to consumers while they wait for their SVI to be resolved. Commenters also indicated that consumers prefer to choose a SEP that has no documentation requirement over a SEP with an SVI requirement as a matter of practicality.

Response: Though enrollment and eligibility should remain as simple as possible to encourage consumer engagement, it must be balanced with a verification process to protect consumers from the real financial and access to care issues that can arise from improper enrollment. Due to unauthorized enrollments, consumers who were originally enrolled in Medicaid and subsequently enrolled in Exchange coverage may experience interruptions in critical medical care as a result of overlapping coverage rules, because Medicaid is generally the payer of last resort and may refuse to pay claims if the consumer is also enrolled in a QHP. Consumers who receive APTCs for which they are not eligible may incur significant tax liabilities, in some cases exceeding $10,000 in a single plan year, for larger households. Though SEP verification could be perceived as a burdensome or unnecessary process, it will help protect the risk pool from adverse selection.

Regarding the suggestion to accept “reliable” attestation, we note that an Exchange generally cannot assess the reliability of an attestation absent supporting documentation. Additionally, even if an Exchange were to accept attestation that it deems reliable, by failing to confirm eligibility through documentation, it could nonetheless facilitate improper enrollments. Nevertheless, we do intend to allow Exchanges to verify at least 75 percent of SEP enrollments because we believe that most Exchanges are able to meet this verification threshold based on current SEP volumes.

We acknowledge that the SEPV requirement adds a minor administrative burden to the enrollment process; however, we are unable to determine whether this burden contributes to consumers foregoing coverage through the Exchange. Consumers may view a single-button re- enrollment process as a convenient option when engaging with the Exchange, but it may also reduce the likelihood that consumers will carefully review their applications or select the SEP most appropriate for their circumstances. As a result, consumers may experience interruptions in coverage or unexpected medical costs. For example, consumers who do not review their applications may remain enrolled in coverage that no longer meets their medical or financial needs, fail to account for changes in plan benefits or provider networks, or neglect to report updated household or income formation that affects eligibility for APTCs. These circumstances may result in gaps in access to care or the reconciliation of excess APTCs on a subsequent tax return.

Awarding temporary coverage to consumers while their SVI is being processed also has the potential to cause harm to consumers. Although we recognize the importance of access to care, consumers who are granted temporary QHP eligibility, use their coverage, and are ultimately found ineligible for the SEP, could become financially responsible for the cost of care received after the issuer cancels coverage and rescinds payment. The current pended plan selection process is required for Exchanges on the Federal platform (which provides that a consumer's enrollment is not effectuated until the Exchange verifies the SVI) balances the consumer's need for access to care while protecting them from unexpected medical costs.

Additionally, granting consumer's eligibility for the 30 days during which their SVI is being processed, regardless of their ability to provide sufficient documentation, could recreate the conditions that initially led to the establishment of SEPV. Allowing temporary eligibility could allow consumers to use a SEP to enroll in coverage only when they need medical care, and then to let the SVI expire and become uninsured after such medical care is received. This would promote adverse selection and could cause significant instability to risk pools. 17. Expansion of Hardship Exemption Eligibility (Sec. 155.605(d)(1))

In the 2027 Payment Notice proposed rule (91 FR 6353), we proposed to amend Sec. 155.605(d)(1) to codify the expansion of hardship exemption eligibility to individuals who are ineligible for APTC or CSR due to projected household income below 100 percent or above 250 percent of the FPL.

Section 5000A(e)(5) of the Code establishes an exemption from the

individual shared responsibility payment based on hardship or lack of affordability, and section 1302(e) of the Affordable Care Act limits eligibility for catastrophic coverage to individuals under age 30 at the start of the plan year or those who have received a hardship or affordability exemption. Under Sec. 155.605(d), hardship exemptions include circumstances that prevent an individual from obtaining coverage through a QHP. Section 155.605(d)(1) states that the Exchange must grant a hardship exemption to an individual for at least the month before, the month or months during which, and the month after a specific event or circumstance, if the Exchange determines that: (1) the individual experienced financial or domestic circumstances, including an unexpected natural or human-caused event, such that he or she had a significant, unexpected increase in essential expenses that prevented him or her from obtaining coverage under a QHP; (2) the expense of purchasing a QHP would have caused the individual to experience serious deprivation of food, shelter, clothing or other necessities; or (3) the individual has experienced other circumstances that prevented him or her from obtaining coverage under a QHP.

State Exchanges may choose to process exemptions, or they may delegate exemption processing to HHS. Most State Exchanges currently delegate hardship exemption processing to HHS.\183\ HHS published guidance on September 4, 2025, that expanded eligibility for a hardship exemption to individuals ineligible for APTC or CSRs due to projected household income for consumers in FFE States, SBE-FP States, and State Exchange States that delegate their exemption processing to HHS.\184\ We stated in the proposed rule that the proposal to amend Sec. 155.605(d)(1) would expand hardship exemption eligibility to consumers ineligible for APTC or CSRs due to projected household income in all States. We proposed to make this change to improve access to affordable coverage for consumers in all States as we believe there are a substantial number of consumers for whom purchasing a QHP relative to a catastrophic plan could cause a financial hardship. From the year before the Affordable Care Act's main regulations took effect in 2013 to 2026, average monthly premiums on the individual market jumped from $244 to $779--a 219 percent increase, with premiums increasing by 26 percent in 2026 alone.\185\ By comparison, inflation since 2013 increased by 39 percent and average hourly earnings for private sector employees increased by 53 percent.\186\As these data show, premiums continue to outpace income growth, creating affordability challenges even for consumers who may not qualify for financial assistance. We stated in the proposed rule that we believe the substantial premium increases accumulated since 2013, and the recent spike in 2026, warrant a broad nationwide hardship exemption to allow individuals aged 30 and older to enroll in catastrophic coverage, if otherwise eligible under the proposed household income parameters. We proposed applying this exemption uniformly across all States to ensure consistent consumer protection and access to catastrophic coverage.

\183\ California, Connecticut, Maryland and the District of Columbia currently do not delegate hardship exemptions processing to HHS.

\184\ CMS. (2025, September 4). Guidance on Hardship Exemptions for Individuals Ineligible for Advance Payment of the Premium Tax Credit or Cost-sharing Reductions Due to Income and Streamlining Exemption Pathways to Coverage. Available at https://www.cms.gov/files/document/guidance-hardship-exemptions.pdf.

\185\ Average enrollment weighted monthly premium from MLR data for 2013, and from unified rate review template (URRT) filings for 2026.

\186\ BLS CPI-U and Current Employment Statistics Survey.

To avoid confusion for consumers, we stated in the proposed rule that States that currently process exemptions independently may implement the expanded criteria within their existing systems or delegate processing to HHS. We stated that this proposal does not preempt State authority under section 1321 of the Affordable Care Act, which provides States flexibility in the operation and enforcement of Exchanges and related requirements. States retain discretion to determine how to operationalize this policy--either by adopting the expanded criteria or continuing to delegate exemption processing to HHS. We also stated that we would provide technical assistance to support implementation and ensure that States can exercise this flexibility while maintaining consistent consumer protection nationwide.

We sought comment on the proposal to amend Sec. 155.605(d)(1) to codify and expand hardship exemptions for individuals who are ineligible for APTC or CSR due to projected household income. If finalized as proposed, the expanded hardship exemption policy would take effect on the effective date of this final rule.

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 this policy as proposed. We summarize and respond to public comments received on the proposed expansion of Hardship Exemption eligibility below.

Comment: A number of commenters stated support for the hardship exemption expansion, citing significant premium increases in recent years and the affordability challenges faced by consumers who do not qualify for APTC or CSR. Commenters noted that having some insurance coverage is better than being uninsured and recommended that CMS pair the expansion with robust consumer education and plan comparison tools to ensure consumers can make informed enrollment decisions.

Response: We appreciate the support stated by these commenters and agree that expanding access to affordable coverage options is an important policy goal. Sustained, market-wide premium increases--219 percent cumulative increase from 2013 to 2026, including a 26 percent increase in 2026 alone,\5\ far outpacing inflation and wage growth over the same period--have created a structural barrier to obtaining coverage for individuals who are not eligible for APTC or CSR to offset those costs. The Secretary has determined that these circumstances constitute a qualifying hardship under section 5000A(e)(5) of the Code--a determination grounded in the documented, market-wide divergence between premium costs and income growth over the same period, which has impaired the capability of certain individuals to obtain coverage under a qualified health plan. For individuals with household income below 100 percent of the FPL or above 400 percent of the FPL who are ineligible for APTC, this premium growth represents a significant barrier to coverage because these individuals cannot reduce the cost of coverage through a premium subsidy, leaving them fully exposed to the cumulative premium increases documented above.\187\ Independent analyses confirm

that this burden is particularly acute for older adults in this income range, who face the highest age-rated premiums in the individual market and, absent subsidy assistance, may spend a substantial share of their income on health insurance premiums.\188\ For individuals with projected annual household income between 250 percent and 400 percent of the FPL who are eligible for APTC but ineligible for CSR, the full cost-sharing burden of metal-level plans presents a distinct but related barrier to the capability to obtain coverage under a qualified health plan: while these individuals may reduce their premium through APTC, they remain ineligible for cost-sharing reductions (CSR), which substantially reduce deductibles, copayments, and out-of-pocket maximums for silver-level plan enrollees--in some cases increasing the effective actuarial value of a silver plan from 70 percent to as high as 94 percent. Without CSRs, these individuals face the full cost- sharing burden of metal-level plans, which may impair their ability to obtain coverage under a qualified health plan even where a premium subsidy is available. This final rule addresses those challenges by expanding hardship exemption eligibility consistent with the Secretary's authority under section 5000A(e)(5) of the Code and section 1302(e) of the Affordable Care Act.

\187\ Average enrollment-weighted monthly premium from MLR data for 2013 ($244) and from Unified Rate Review Template (URRT) filings for 2026 ($779), reflecting a 219 percent cumulative increase and a 26 percent increase in 2026 alone. See CMS, 2027 Payment Notice Proposed Rule, 91 FR 6292, 6353 n.123 (Feb. 11, 2026). By comparison, inflation increased 39 percent over the same period. See Bureau of Labor Statistics, U.S. Dep't of Labor, Consumer Price Index for All Urban Consumers (CPI-U): U.S. City Average, All Items, available at https://www.bls.gov/cpi/. Average hourly earnings for private sector employees increased 53 percent over the same period. See Bureau of Labor Statistics, U.S. Dep't of Labor, Current Employment Statistics Survey: Average Hourly Earnings of All Employees, Total Private, available at https://www.bls.gov/ces/.

\188\ How Will the Loss of Enhanced Premium Tax Credits Affect Older Adults?, KFF (2025), available at https://www.kff.org/affordable-care-act/how-will-the-loss-of-enhanced-premium-tax-credits-affect-older-adults/.

Catastrophic plans are intended as a safety-net against total uninsurance--providing meaningful protection against devastating medical expenses and ensuring access to preventive care for consumers who would otherwise be uninsured. This final rule expands the range of coverage options available to consumers; it does not mandate enrollment in any particular plan type. Consumers may use the plan comparison tools and resources available on HealthCare.gov to evaluate all available options and select the plan that best meets their individual needs and circumstances. The available enrollment data support this conclusion: according to CMS' 2026 Marketplace Open Enrollment Period Public Use Files, of the 23.1 million consumers who selected health insurance coverage during the 2026 Open Enrollment Period--the first following the effective date of the September 2025 guidance expanding hardship exemption eligibility--only 67,489, or less than 0.3 percent, selected a catastrophic plan,\189\ demonstrating that consumers who can afford QHP coverage are, in practice, continuing to choose QHPs rather than catastrophic plans. We will continue to ensure that HealthCare.gov provides clear, accessible information about catastrophic plans, including what is and is not covered before the deductible is met, the absence of dental benefits, that APTC and PTC can only be applied to metal-level QHPs, and that consumers who qualify for the premium tax credit or cost-sharing reductions should compare Bronze and Silver plans, as those plans may be a better value.\190\ We acknowledge, however, that catastrophic plans have low monthly premiums and very high deductibles, and that they are intended as a safety-net against total uninsurance--not as a preferred coverage option for individuals with serious illness, complex conditions, or ongoing health care needs. Consumers with regular health care needs may face significant out-of- pocket costs before most benefits are covered, and individuals enrolled in catastrophic plans do not qualify for PTCs. This final rule expands consumer choice; it does not require any individual to enroll in a catastrophic plan, and it is not intended to steer consumers with significant health care needs away from comprehensive metal-level coverage.

\189\ See How Will the Loss of Enhanced Premium Tax Credits Affect Older Adults?, KFF (2025) at https://www.kff.org/affordable-care-act/how-will-the-loss-of-enhanced-premium-tax-credits-affect-older-adults/.

\190\ See Catastrophic Health Plans, HealthCare.gov, available at https://www.healthcare.gov/choose-a-plan/catastrophic-health-plans/, Health Savings Account Options, HealthCare.gov, available at https://www.healthcare.gov/hsa-options/, What Marketplace Health Insurance Plans Cover, HealthCare.gov, available at https://www.healthcare.gov/coverage/what-marketplace-plans-cover/.

Comment: Several commenters stated that the proposed expansion of hardship exemption eligibility exceeds the Secretary's statutory authority and constitutes an unlawful attempt to circumvent the affordability exemption standard established by Congress. Commenters noted that Congress deliberately limited catastrophic plan eligibility to three groups, individuals under age 30, individuals who qualify for an affordability exemption under section 5000A(e)(1) of the Code, and individuals who qualify for a hardship exemption under section 5000A(e)(5), and that the proposed rule effectively rewrites these statutory eligibility criteria.

Commenters further noted that Congress constructed a narrow affordability exemption under section 5000A(e)(1) of the Code with specific income-based eligibility criteria and an indexing mechanism under section 5000A(e)(1)(D) that was specifically designed to account for the divergence between premium growth and income growth over time. Commenters stated that the existence of this indexing mechanism reflects a deliberate congressional judgment about how to address premium growth relative to income and that the Secretary cannot use the hardship exemption authority in section 5000A(e)(5) of the Code to create a broader, income-based pathway to catastrophic coverage that replaces or supersedes that statutory standard. In commenters' view, the proposed rule would make catastrophic plans available to approximately 80 percent of adults aged 18-64--including everyone with income below 100 percent of the FPL (approximately $15,650 for a single person) and everyone with income above 250 percent of the FPL (approximately $39,125 for a single person)--a population that commenters noted Congress never intended to have access to catastrophic coverage on a broad, categorical basis.

Commenters also noted that the hardship exemption is limited to individualized, circumstance-specific situations such as an unexpected increase in essential expenses, deprivation of food, shelter, or clothing, or other specific circumstances preventing an individual from obtaining QHP coverage and that the proposed rule adds an income-based exemption without a direct link to the capability to obtain QHP coverage. Some commenters noted that an individual with income above 250 percent of the FPL who could afford a QHP would nonetheless qualify for catastrophic coverage under the proposal, further undermining the connection to hardship. A few commenters requested CMS to withdraw the proposal entirely and to revoke the September 2025 sub-regulatory guidance that initially introduced the expanded eligibility.

Commenters further noted that Congress recently made catastrophic plans eligible to be paired with health savings accounts (HSAs) without amending the statutory eligibility criteria for catastrophic coverage, and that legislation that would have codified and expanded upon CMS' September 2025 guidance, the Health Care Freedom for Patients Act, was considered but not enacted by Congress in December 2025. Commenters stated that these legislative developments reflect a deliberate

congressional judgment against expanding catastrophic plan eligibility in the manner proposed.

Response: We have carefully considered the statutory authority concerns raised by commenters and provide the following explanation of the legal framework underlying this final rule.

Section 1302(e)(2)(B) of the Affordable Care Act establishes two independent, coordinate pathways to catastrophic plan eligibility based on exemption status: eligibility under section 5000A(e)(1) of the Code (relating to individuals for whom coverage is unaffordable) and eligibility under section 5000A(e)(5) of the Code (relating to individuals who have suffered a hardship for the capability to obtain QHP coverage). The statute does not establish a hierarchy between these two pathways, nor does it provide that the hardship pathway is constrained by the criteria Congress established for the separate affordability exemption. This final rule exercises the Secretary's authority under section 5000A(e)(5) of the Code, a distinct statutory provision, and does not modify, replace, or supersede the affordability exemption standard under section 5000A(e)(1) of the Code.

Section 5000A(e)(5) of the Code grants the Secretary of HHS authority to determine whether an individual has “suffered a hardship for the capability to obtain coverage under a qualified health plan.” This provision grants the Secretary discretion to define the circumstances that constitute a qualifying hardship. The statute does not enumerate or limit those circumstances, nor does it require that the hardship exemption be unavailable to individuals who also fail to qualify for the affordability exemption.

We acknowledge that Congress established specific criteria for the affordability exemption under section 5000A(e)(1) of the Code, including an indexing mechanism under section 5000A(e)(1)(D) to account for premium growth relative to income growth. The existence of that indexing mechanism reflects Congress' approach to the affordability exemption; it does not, however, limit the Secretary's separate authority under section 5000A(e)(5) of the Code to recognize that the cumulative divergence between premium growth and income growth--a 219 percent increase in average monthly premiums from 2013 to 2026, including a 26 percent increase in 2026 alone, far outpacing inflation (39 percent) and wage growth (53 percent) over the same period \191\-- constitutes a hardship for the capability to obtain QHP coverage for a broad population of consumers. The affordability exemption under section 5000A(e)(1) of the Code does not fully account for this hardship for the population addressed by this rule, as described below for each income group. For individuals with a projected household income below 100 percent of the FPL, the hardship exemption under section 5000A(e)(5) of the Code provides an independent and appropriate pathway to relief that operates separately from the affordability exemption calculation. These individuals are generally ineligible for APTC because they are assumed to be eligible for Medicaid--but not all individuals with household income below 100 percent of the FPL are eligible for or enrolled in Medicaid. Certain individuals may be ineligible for Medicaid due to immigration status, categorical eligibility requirements, value of property they own, or other factors, meaning the assumption of Medicaid eligibility that underlies APTC ineligibility based on income does not reflect their actual access to coverage. For these individuals, the hardship exemption under section 5000A(e)(5) addresses a distinct structural barrier--the gap between assumed and actual coverage access--that the affordability exemption framework does not resolve.

\191\ CMS analysis of individual market premium data, 2013-2026. See 91 FR 6292, 6354 (Feb. 11, 2026).

For individuals with household income above 400 percent of the FPL who are ineligible for APTC, the full unsubsidized premium cost--which has increased 219 percent since 2013--may or may not exceed the affordability exemption threshold depending on their specific income level, but the hardship exemption under section 5000A(e)(5) provides an independent and appropriate pathway to relief for this population through two pathways.\192\ Under the first pathway, individuals who apply for coverage through the Exchange and attest to a projected household income above 400 percent of the FPL--rendering them ineligible for APTC--will have the hardship exemption automatically adjudicated based on the income information provided in their coverage application. Under the second pathway, individuals may apply directly for the hardship exemption by completing the paper exemption request form \193\ and attesting that they cannot afford coverage because they are no longer eligible for financial assistance; income documentation is not required under this pathway. Both pathways are consistent with the attestation-based framework governing hardship exemption eligibility under Sec. 155.605(d)(1)(iii), eligibility is based on the individual's attested projected household income; no documentation of hardship circumstances is required.

\192\ HHS Expands Access to Affordable Health Insurance, available at https://www.hhs.gov/press-room/hhs-expands-access-affordable-catastrophic-health-coverage.html.

\193\ See Health Coverage Exemptions: Forms & How to Apply, HealthCare.gov, available at https://www.healthcare.gov/health-coverage-exemptions/forms-how-to-apply/.

For individuals with projected annual household income between 250 percent and 400 percent of the FPL who are eligible for APTC but ineligible for CSR, the hardship determination rests on a distinct but related basis. While these individuals may reduce their monthly premium through APTC, they remain ineligible for cost-sharing reductions (CSR), which are available only to individuals with household income at or below 250 percent of the FPL enrolled in silver-level plans. CSRs substantially reduce deductibles, copayments, and out-of-pocket maximums--in some cases increasing the effective actuarial value of a silver plan from 70 percent to as high as 94 percent. Without CSRs, individuals in this income range face the full cost-sharing burden of metal-level plans, which may render coverage financially inaccessible as a practical matter even where a premium subsidy is available.

The two exemption pathways address overlapping but distinct circumstances and operate independently of one another. Both pathways respond to the same underlying market condition--sustained, market-wide premium increases that have outpaced inflation and wage growth, creating barriers to obtaining coverage under a QHP. They are distinct, however, in the circumstances each addresses: the affordability exemption under section 5000A(e)(1) of the Code applies a specific, formulaic calculation based on whether the cost of the lowest-cost bronze plan, reduced by any available APTC, exceeds the applicable percentage of household income; the hardship exemption under section 5000A(e)(5) of the Code addresses structural barriers to the capability to obtain coverage that fall outside that formula--including APTC ineligibility due to assumed Medicaid eligibility that does not reflect actual coverage access, the full cost-sharing burden faced by individuals between 250 percent and 400 percent of the FPL who are

ineligible for CSR, and the impact of non-discretionary expenses on the income available for premiums and cost-sharing for individuals above 400 percent of the FPL. The indexing mechanism in section 5000A(e)(1)(D) governs the affordability exemption; it does not constrain the Secretary's independent authority under section 5000A(e)(5) of the Code to respond to the same underlying market conditions through the hardship pathway.

For the characterization of the hardship exemption as limited to individualized, event-specific circumstances, we note that the existing regulatory framework does not support that reading. The hardship exemption eligibility standards at Sec. 155.605(d) were originally established in the 2013 final rule.\194\ That rule established, among other things, a broad “other circumstances” category at Sec. 155.605(d)(1)(iii) under which the Exchange must grant a hardship exemption to an individual who “has experienced other circumstances that prevented him or her from obtaining coverage under a qualified health plan.” The original preamble to Sec. 155.605 explicitly noted that the hardship exemption was drafted with “broad language to include a range of personal scenarios” and that we expected to “clarify these criteria in future guidance,” \195\ reflecting the Secretary's longstanding exercise of discretion to define and expand hardship criteria over time.

\194\ Patient Protection and Affordable Care Act; Exchange Functions: Eligibility for Exemptions; Miscellaneous Minimum Essential Coverage Provisions, 78 FR 39494 (July 1, 2013).

\195\ 78 FR 39494, 39510 (July 1, 2013).

Moreover, the use of income-based, categorical criteria in the hardship exemption is not a new development. The Medicaid non-expansion exemption at Sec. 155.605(d)(3) provides a particularly instructive precedent. That exemption was established to address the hardship faced by individuals who were ineligible for Medicaid solely because their State chose not to expand Medicaid eligibility under the Affordable Care Act. As we noted in the 2013 final rule, the Secretary determined that it was appropriate for individuals to be eligible for this hardship exemption even if they remained technically eligible for APTC, recognizing that technical eligibility for a subsidy does not, by itself, ensure that coverage is meaningfully accessible or affordable.\196\ This precedent is directly applicable to individuals between 250 percent and 400 percent of the FPL who are eligible for APTC but ineligible for CSR--for whom the absence of cost-sharing reductions may render coverage financially inaccessible as a practical matter even where a premium subsidy is available. For individuals above 400 percent of the FPL who are ineligible for APTC, the hardship determination is grounded in the individual's attested income or hardship situation, depending on the exemption request pathway (automated or paper form) used. As described previously, the two pathways are consistent with the attestation-based framework governing hardship exemption eligibility under Sec. 155.605(d)(1)(iii) to ensure that the exemption is grounded in an affirmative attestation by the individual, whether of income or of hardship circumstance. The threshold of 400 percent of the FPL is not a fixed measure of financial capacity: the income available for health insurance premiums and cost sharing is further reduced by other essential, non-discretionary expenses--including housing, childcare, eldercare, and other obligations--that are not accounted for in the affordability exemption calculation under section 5000A(e)(1) of the Code. For individuals in this income range for whom those circumstances, combined with the documented, sustained divergence between premium costs and income growth--a 219 percent cumulative increase in average monthly premiums from 2013 to 2026,\197\ far outpacing inflation and wage growth over the same period--have impaired the capability to obtain coverage under a qualified health plan, the hardship exemption under section 5000A(e)(5) provides an appropriate and independent pathway to relief. As described previously, neither the automatic determination nor the paper exemption request form pathways require documentation, and both ensure that the exemption is grounded in an affirmative attestation by the individual--whether of income or of hardship circumstance-- consistent with the attestation-based framework governing hardship exemption eligibility under Sec. 155.605(d)(1)(iii).

\196\ See 78 FR 39494 at 39514-15.

\197\ Average enrollment-weighted monthly premium from MLR data for 2013 ($244) and from Unified Rate Review Template (URRT) filings for 2026 ($779), reflecting a 219 percent cumulative increase and a 26 percent increase in 2026 alone. See 91 FR 6292, 6353 n.123 (Feb. 11, 2026). By comparison, inflation increased 39 percent over the same period. See Bureau of Labor Statistics, Consumer Price Index for All Urban Consumers (CPI-U), available at https://www.bls.gov/cpi/. Average hourly earnings for private sector employees increased 53 percent over the same period. See Bureau of Labor Statistics, Current Employment Statistics Survey: Average Hourly Earnings of All Employees, Total Private, available at https://www.bls.gov/ces/.

We further operationalized the Medicaid non-expansion exemption through sub-regulatory guidance issued on November 21, 2014, which established that an individual residing in a State that did not expand Medicaid coverage with household income below 138 percent of the FPL was eligible to claim a hardship exemption--a categorical, income-based determination made without requiring individualized proof of circumstance-specific hardship.\198\ The 2016 final rule further streamlined the Medicaid non-expansion exemption by eliminating the requirement for a denial notice for applicants ineligible for Medicaid because their State did not expand Medicaid coverage, reflecting our ongoing exercise of administrative discretion to reduce barriers to exemption access for populations facing systemic coverage gaps.\199\

\198\ CMS, Hardship Exemption Guidance for Persons Meeting Certain Criteria (Nov. 21, 2014). See: https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/Hardship-Exemption-Guidance-11-21-14-final.pdf.

\199\ Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2017, 81 FR 12204, 12267-68 (Mar. 8, 2016).

While regulatory precedent is not itself dispositive of statutory authority, the Medicaid non-expansion exemption is instructive as evidence of the Secretary's longstanding, consistent, and unchallenged exercise of the same authority under section 5000A(e)(5) of the Code in a comparable context. That precedent supports the following features of the current proposal as applied to individuals between 250 percent and 400 percent of the FPL who are eligible for APTC but ineligible for CSR: (1) the use of categorical, income-based criteria to define a qualifying hardship; (2) the availability of a hardship exemption to individuals who retain some technical access to subsidized coverage; and (3) the Secretary's authority to recognize systemic, structural barriers to coverage--not merely individualized, event-specific circumstances--as qualifying hardships under section 5000A(e)(5). The expansion codified in this final rule is consistent with and builds upon that established regulatory history.

For individuals with projected annual household income above 400 percent of the FPL who are ineligible for APTC, the hardship determination rests on independent grounds, as described above: the 400 percent FPL threshold is not a uniform measure of financial capacity-- the income available for health insurance premiums and cost sharing is further reduced by other

essential, non-discretionary expenses not accounted for in the affordability exemption calculation under section 5000A(e)(1) of the Code. For individuals in this income range for whom those circumstances, combined with the sustained, market-wide premium increases documented above, have impaired the capability to obtain coverage under a qualified health plan, the hardship exemption under section 5000A(e)(5) provides an appropriate and independent pathway to relief. As mentioned previously, the automated and paper form pathways are grounded in the attestation-based framework governing hardship exemption eligibility under Sec. 155.605(d)(1)(iii). For the statement that an individual with an income above 250 percent of the FPL who could afford a non-catastrophic QHP would nonetheless qualify for catastrophic coverage under the proposal, we note that this concern does not accurately reflect the purpose or practical effect of this policy. This rule is designed to expand coverage options for consumers who face structural barriers to affordable coverage--not to redirect consumers away from non-catastrophic QHPs. Consumers who can afford and prefer a non-catastrophic QHP remain free to enroll in one; this rule does not alter that choice. The hardship exemption expands the range of options available to consumers, consistent with the Secretary's authority under section 5000A(e)(5) to define qualifying hardship circumstances.

We note that the hardship exemption expansion does not create a new entitlement or mandate enrollment in catastrophic coverage--it expands the range of options available to consumers who face structural barriers to obtaining coverage under a qualified health plan. The policy's purpose is to ensure that consumers who cannot meaningfully access metal-level coverage have a pathway to some coverage, consistent with the Secretary's authority under section 5000A(e)(5) of the Code.

For individuals between 250 percent and 400 percent of the FPL who remain eligible for APTC, we note that, for individuals who are ineligible for CSR, APTC eligibility alone does not ensure that coverage is meaningfully affordable or adequate. Individuals in this income range are not eligible for CSR, which are available only to individuals with household income at or below 250 percent of the FPL enrolled in silver-level plans. CSRs substantially reduce deductibles, copayments, and out-of-pocket maximums--in some cases increasing the effective actuarial value of a silver plan from 70 percent to as high as 94 percent.\200\ Without CSRs, individuals between 250 percent and 400 percent of the FPL face the full cost-sharing burden of metal-level plans, which may render those plans financially inaccessible as a practical matter even where APTC is available. As we recognized in the context of the Medicaid non-expansion exemption--where some individuals technically eligible for APTC were nonetheless deemed to face a qualifying hardship--the Secretary's determination that a population faces a qualifying hardship is grounded in the practical and financial realities of coverage access, not merely in technical subsidy eligibility.

\200\ See 42 U.S.C. 18071 (requiring issuers to reduce cost- sharing for eligible low-income enrollees in silver plans); 45 CFR 156.420 (establishing the cost-sharing reduction variants for silver plans at 73, 87, and 94 percent actuarial value).

For the request to revoke the September 4, 2025, sub-regulatory guidance, we decline to do so. That guidance was issued under the Secretary's authority under section 5000A(e)(5) and section 1311(d)(4)(H) of the Affordable Care Act,\201\ and this final rule codifies and extends that guidance consistent with the same legal authority.

\201\ See 42 U.S.C. 18031(d)(4)(H) authorizing the Secretary to establish additional criteria for certifying health plans as qualified health plans, including such other criteria as the Secretary determines appropriate).

For the statement that Congress' decision not to enact the Health Care Freedom for Patients Act, or its decision not to amend the statutory eligibility criteria when making catastrophic plans eligible to be paired with HSAs, reflects a congressional judgment against expanding catastrophic plan eligibility, we note that the failure of legislation to pass does not, as a general matter, constitute a prohibition on agency action within existing statutory authority.\202\ The Secretary's authority under section 5000A(e)(5) exists independently of any subsequent legislative proposals. This final rule is grounded in the text, structure, and purpose of both section 1302(e) of the Affordable Care Act and section 5000A(e)(5) of the Code, and we are finalizing this provision accordingly.

\202\ See Pension Benefit Guaranty Corp. v. LTV Corp., 496 U.S. 633, 650 (1990) (“It is a particularly dangerous ground on which to rest an interpretation of a prior statute when it concerns . . . a proposal that does not become law.”) (citing United States v. Price, 361 U.S. 304, 313 (1960)).

Comment: Several commenters expressed concern that expanding hardship exemption eligibility would destabilize the individual market risk pool. Because catastrophic plans are included in a separate risk pool from metal-level plans under the HHS-operated risk adjustment program, commenters stated that drawing healthier enrollees into catastrophic coverage could increase premiums for those remaining in metal-level plans. Commenters specifically characterized this dynamic as drawing consumers from “high-actuarial value (AV) plans to low- value plans,” weakening the broader Exchanges. Commenters further stated that CMS is effectively creating a parallel catastrophic insurance market that would compete with metal-level Exchange plans, an outcome they contended is contrary to the Affordable Care Act's design and structure. Commenters requested that CMS evaluate how the expanded eligibility interacts with the methodology of the HHS-operated risk adjustment program to ensure that risk adjustment transfers accurately reflect the relative health risk of enrollees across plan types and support market stability, including by pooling catastrophic and non- catastrophic plan risk calculations under the State payment transfer formula to create a larger, more resilient risk pool.

Commenters also noted concerns about the interaction between the hardship exemption eligibility expansion and other proposed changes to catastrophic coverage, including the proposed allowance of multi-year catastrophic plan terms at Sec. Sec. 156.130(c) and 156.155(a)(6) and proposed cost-sharing modifications at Sec. 156.155(a)(3). Commenters stated that the cumulative effect of these changes could accelerate adverse selection dynamics, drawing younger and healthier consumers away from comprehensive metal-level plans and raising premiums for those who remain in those plans. Community health advocates warned of a “dual harm” scenario in which patients enrolled in catastrophic plans delay or avoid needed care due to high-deductible barriers--undermining continuity of care and worsening health outcomes--while community health centers simultaneously experience revenue loss and increased uncompensated care burden. At least one commenter stated that the proposal is counter to sound public policy and should be withdrawn. Commenters also requested that CMS conduct and publish an actuarial analysis quantifying the projected impact on Exchange risk pools, premiums, and Federal subsidy costs before implementation.

Response: We have carefully considered the risk pool concerns raised by commenters. We acknowledge that catastrophic plans are included in the

single risk pool for the individual market; however, catastrophic plans are subject to separate risk adjustment calculations under the HHS- operated risk adjustment program. Because catastrophic plans are subject to separate risk adjustment calculations, catastrophic plans that enroll lower-risk individuals than metal-level plans do not compensate metal-level plans for enrolling higher-risk individuals through risk adjustment transfers. We acknowledge that this dynamic, and changes in enrollment patterns more broadly, may affect the composition of the individual market risk pool. However, these concerns do not outweigh the significant and well-documented barriers the Secretary has determined have prevented a broad population of consumers from obtaining coverage under a QHP, constituting a qualifying hardship under section 5000A(e)(5). As described previously in this final rule, the Secretary has determined that the income-group-specific circumstances faced by each of these populations--including sustained, market-wide premium increases and, for individuals between 250 percent and 400 percent of the FPL, the full cost-sharing burden of metal-level plans in the absence of CSR--constitute a qualifying hardship with respect to the capability to obtain QHP coverage under section 5000A(e)(5).\203\

\203\ CMS analysis of individual market premium data, 2013-2026. See 91 FR 6292, 6354 (Feb. 11, 2026).

For the characterization of this policy as creating a “parallel insurance market” that competes with metal-level Exchange plans, we note that catastrophic plans have always been available through the Exchanges alongside metal-level plans for eligible consumers and all plans--including catastrophic plans--remain subject to the same QHP certification requirements, consumer protection standards, and essential health benefit requirements that apply to all Exchange plans.\204\ We acknowledge, however, that expanding the population eligible for catastrophic coverage has the potential to affect the composition of the individual market risk pool, and we do not minimize that concern.

\204\ See 45 CFR 156.200 (QHP certification standards); 42 U.S.C. 18022(b) (essential health benefits).

We have considered the request to combine risk adjustment transfer calculations for catastrophic and non-catastrophic plans under the State payment transfer formula. We are not combining these calculations in this final rule. As discussed in section III.E.6 of this final rule (Sec. 156.155(a)(6)), we believe the existing HHS risk adjustment methodology is flexible enough to appropriately accommodate catastrophic plans--including multi-year catastrophic plans--without changes to the HHS risk adjustment models or State payment transfer formula. Risk adjustment transfers for catastrophic plans will continue to be calculated separately from metal-level plans on a plan year basis, consistent with current practice. This applies equally to multi- year catastrophic plans, for which risk adjustment transfers will continue to be calculated on a plan year basis, as described in section III.E.6 of this final rule.

We acknowledge that if catastrophic plan enrollment grows substantially, maintaining separate risk adjustment calculations for catastrophic and non-catastrophic plans could have a more pronounced effect on premiums for metal-level plans. The available enrollment data from the first Open Enrollment Period following the effective date of the September 2025 guidance--during which only 67,489 consumers, or less than 0.3 percent of the 23.1 million total plan selections, selected a catastrophic plan--demonstrates that the actual impact on the metal-level risk pool has been minimal to date. This minimal uptake is consistent with the risk pool assumptions underlying 2027 rate submissions and demonstrates that consumers who can afford and prefer metal-level coverage are, in practice, continuing to choose metal-level plans. We will monitor catastrophic plan enrollment, and risk profile, and will consider whether changes to the HHS risk adjustment methodology--including whether to combine catastrophic and non- catastrophic risk adjustment calculations--are warranted through future notice-and-comment rulemaking.

For the “dual harm” concern raised by community health advocates--that patients enrolled in catastrophic plans may delay or avoid needed care due to high-deductible barriers, while community health centers simultaneously experience revenue loss and increased uncompensated care burden--we note that this concern applies broadly to high-deductible coverage and is not unique to the expanded hardship exemption. Catastrophic plans have always been available to eligible consumers, and the expanded eligibility does not alter the cost-sharing structure of those plans. Moreover, by reducing the number of uninsured, we expect that broadening access to catastrophic coverage will improve revenues and reduce uncompensated care burdens for community health centers. We note that the hardship exemption expansion benefits consumers broadly--it is not targeted at or limited to any particular geographic community or health center service area, and the policy's consumer protection benefits accrue to individuals regardless of where they receive care. As discussed in section III.E.7. of this final rule, to the extent permitted by applicable Federal and State law, issuers of catastrophic plans may offer arrangements designed to reduce the up-front financial barrier associated with high deductibles. Such arrangements could be designed to reduce the up-front financial barrier that can lead to delayed or avoided care.

For the request to withdraw the proposal, we decline to do so for the reasons set forth throughout this final rule.

For the request that CMS conduct and publish an actuarial analysis quantifying the projected impact on Exchange risk pools, premiums, and Federal subsidy costs before implementation of this policy, we note that we will continue to monitor market conditions and enrollment trends and will transparently report on these impacts as data from PY 2026 becomes available.

We note that the hardship exemption guidance underlying this codification was issued on September 4, 2025--sufficiently in advance of PY 2027 rate filing cycle--and that the streamlined online application process launched November 1, 2025, the start of the 2026 Open Enrollment period.\205\ Issuers therefore had the opportunity to account for the expanded eligibility in their 2027 rate submissions. The September 4, 2025 guidance was in effect beginning November 1, 2025--the start of the 2026 Open Enrollment Period--and issuers filing 2027 rates during the standard rate review period were able to draw on actual 2026 enrollment experience under the expanded eligibility when developing their 2027 rate submissions.\206\ We do not anticipate that this particular provision will materially disrupt 2027 rate filings because issuers had both advance notice of the expanded eligibility and the

opportunity to observe actual enrollment behavior under the expanded criteria prior to submitting their 2027 rates. As noted above, the 2026 Open Enrollment Period data confirms that catastrophic plan uptake under the expanded eligibility was minimal \207\--consistent with the risk pool assumptions underlying 2027 rate submissions.

\205\ CMS, Expanding Access to Health Insurance: Consumers to Gain Access to “Catastrophic” Health Insurance Plans in 2026 Plan Year (Sept. 4, 2025), available at https://www.cms.gov/newsroom/fact-sheets/expanding-access-health-insurance-consumers-gain-access-catastrophic-health-insurance-plans-2026.

\206\ See CMS, 2026 Rate Review Timeline Bulletin (describing the standard rate filing and review schedule for plan year 2027), available at https://www.cms.gov/files/document/2026-rate-review-timeline-bulletin.pdf.

\207\ See CMS, 2026 Marketplace Open Enrollment Period Public Use Files.

This rule expands the criteria under which individuals may qualify for a hardship exemption under Sec. 155.605(d)(1); it does not alter the rules governing the exemption itself, including the annual nature of exemption eligibility. Concerns about catastrophic plan design-- including risk adjustment methodology, multi-year plan terms (including the eligibility carry-through question for individuals who qualify based on a hardship exemption at initial enrollment in a multi-year term), and cost-sharing parameters--are addressed in sections III.E.2 (Sec. 156.80(d)(2)(ii)), III.E.6. (Sec. 156.155(a)(6)), and III.E.7. (Sec. 156.155(a)(3)) of this final rule.

Consumers retain full freedom of choice in the Exchanges. Individuals who qualify for this hardship exemption are not required to enroll in catastrophic coverage--they may continue to shop for and enroll in any available metal-level plan, if eligible. We will continue to monitor market conditions, enrollment trends, and the impact of the expanded eligibility on metal-tier risk pools, premiums, and serious- illness populations, and will transparently report on these impacts as data from PY 2026 becomes available. We are committed to considering corrective regulatory action in future rulemaking if monitoring data reveals material harm to the risk pool or to consumers with serious illness or complex health care needs. Concerns about multi-year catastrophic plan protections--including right to transition to other coverage, such as a metal-level plan, during a special enrollment period triggered by a qualifying life event and pre-enrollment counseling for high-risk applicants--are addressed in section III.E.6. of this final rule.

Comment: Commenters stated concern that expanding access to catastrophic plans through the hardship exemption would expose consumers--particularly those with chronic conditions, complex health needs, or limited financial resources--to unaffordable out-of-pocket costs. Commenters noted that catastrophic plans do not cover services other than preventive services and three primary care visits until an enrollee reaches the annual maximum out-of-pocket limit, and that most care would not be covered until an individual spends $15,600 (individual) or $31,200 (family) in a single year. Some commenters characterized catastrophic plans as “junk” coverage that shifts the entire burden of health care risk onto the individual and urged CMS to focus on lowering out-of-pocket costs rather than expanding access to plans with limited pre-deductible coverage.

Commenters also raised concern that consumers eligible for APTC could be targeted by aggressive marketing and induced to enroll in catastrophic coverage based on lower premiums, without fully understanding the coverage limitations. Commenters emphasized that APTC-eligible consumers should not be encouraged to forgo tax credits in favor of catastrophic plans that offer less comprehensive coverage and higher cost-sharing exposure. The underinsurance risk was also highlighted: while catastrophic plans offer protection against major medical events for individuals with low-to-no-health care needs, consumers with routine or ongoing health care needs may face thousands of dollars in out-of-pocket costs before any meaningful coverage applies.

One commenter noted that catastrophic plans generally do not include dental benefits, and that consumers--especially those with limited financial flexibility--may not realize they need to purchase a separate SADP to maintain access to oral health services.\208\ Additional commenters raised concerns about the disproportionate impact of high-deductible catastrophic plans on individuals with complex or chronic conditions and about consumers who may not fully understand the limitations of catastrophic coverage at the time of enrollment.

\208\ See 42 U.S.C. 18022(b)(1) (essential health benefits); 45 CFR 156.110 (adult dental and vision coverage are not EHBs).

Response: We acknowledge these concerns and recognize that catastrophic plans are not the right fit for every consumer. This final rule expands consumer choice--it does not require any individual to enroll in a catastrophic plan and it does not create disparate advantage for catastrophic plans over metal level plans in any way.

Catastrophic plans cover the same 10 EHBs as other Exchange plans, including preventive services at no cost, and cover at least three primary care visits per year before the deductible is met.\209\ These plans are specifically designed to provide financial protection against worst-case scenarios, such as serious illness or injury that could result in devastating medical expenses. For consumers who are currently uninsured because they cannot afford a metal-level plan, access to catastrophic coverage could provide meaningful protection and ensure access to preventive care.

\209\ CMS, Expanding Access to Health Insurance: Consumers to Gain Access to “Catastrophic” Health Insurance Plans in 2026 Plan Year (Sept. 4, 2025), available at https://www.cms.gov/newsroom/fact-sheets/expanding-access-health-insurance-consumers-gain-access-catastrophic-health-insurance-plans-2026.

We acknowledge, however, that catastrophic plans have low monthly premiums and very high deductibles, and that they are intended as a safety-net against total uninsurance--not as a preferred coverage option for individuals with serious illness, complex conditions, or ongoing health care needs. Consumers who are concerned about exposure to high deductibles may also wish to explore additional coverage options, such as supplemental insurance products for hospital indemnity, critical illness, or accidents -- that may help offset deductible costs, which in some circumstances may be a preferred complement or alternative to a higher-premium metal-level plan. Consumers should carefully evaluate the terms, limitations, and costs of any supplemental product before purchasing. Consumers with regular health care needs may face significant out-of-pocket costs before most benefits are covered, and individuals enrolled in catastrophic plans do not qualify for PTC. This final rule expands consumer choice; it does not require any individual to enroll in a catastrophic plan, and it is not intended to steer consumers with significant health care needs away from comprehensive metal-level coverage. As HealthCare.gov advises, consumers who qualify for PTC or CSR should compare bronze and silver plans, as those plans may be a better value.

Consumers will have full visibility into their APTC and CSR eligibility upon completing their Exchange application. The plan shopping experience on HealthCare.gov is designed to present consumers with personalized eligibility information and plan comparison tools that clearly display premiums after tax credits, cost-sharing obligations, and coverage differences across all available plan

types.\210\ Consumers who are eligible for APTC will be able to see the net premium cost of metal-level plans after applying their tax credits, enabling a fully informed comparison before selecting a catastrophic plan. We will continue to enforce applicable marketing standards and nondiscrimination requirements to ensure that issuers, agents, and brokers present catastrophic plan options accurately and do not steer consumers toward or away from particular plan types based on health status or other protected characteristics.\211\ Consumers who are eligible for APTC should be made aware that those credits can only be applied to metal-level QHPs--not to catastrophic plans--and that forgoing APTC in favor of a lower-premium catastrophic plan may result in significantly higher total health care costs, particularly for individuals with ongoing health care needs. We will continue to ensure that HealthCare.gov provides clear, accessible information about catastrophic plans--including that APTC can only be applied to metal- level QHPs and that forgoing APTC in favor of a catastrophic plan may result in higher total health care costs--so that consumers can make fully informed coverage decisions.

\210\ See HealthCare.gov, How to Pick a Health Insurance Plan, available at https://www.healthcare.gov/choose-a-plan/.

\211\ See 45 CFR 155.220 (standards for agents and brokers).

For the dental coverage gap, catastrophic plans do not include dental benefits, and consumers enrolling in catastrophic coverage who wish to maintain access to dental services should consider purchasing a separate SADP. We will ensure that consumer education resources clearly communicate this limitation.\212\ We are expanding the criteria under which individuals may qualify for a hardship exemption under Sec. 155.605(d)(1); it does not alter the exemption redetermination process or the rules governing catastrophic plan design. Concerns about the catastrophic plan design--including cost-sharing modifications, multi- year catastrophic plan terms, plan-level adjustments, and risk adjustment methodology--are addressed in sections III.E.7. (Sec. 156.155(a)(3)), III.E.6. (Sec. 156.155(a)(6)), and III.E.2. (Sec. 156.80(d)(2)(ii)) of this final rule. The available enrollment data, as discussed previously, demonstrate that consumer uptake of catastrophic coverage under the expanded eligibility has been minimal, which is consistent with the risk pool assumptions underlying those provisions.

\212\ See HealthCare.gov, What Marketplace Health Insurance Plans Cover, available at https://www.healthcare.gov/coverage/.

Comment: Commenters raised concerns about the proposal's interaction with State-level individual mandate laws and State-run hardship exemption processing systems. Some commenters stated appreciation for HHS' recognition that States are in the best position to regulate their individual insurance markets and for allowing each State to determine what products are sold, while raising concerns about the practical implications of the Federal expansion of eligibility for catastrophic coverage for States with their own mandates and exemption frameworks. Commenters requested that States that enforce their own individual mandates or process their own hardship exemptions retain sole discretion to determine the scope of their hardship exemptions, and that CMS exempt such States from any requirement to broaden hardship exemption eligibility for catastrophic coverage.

One State Exchange reported that no carriers currently offer catastrophic plans through its platform, representing a complete on- exchange market withdrawal by carriers that had sold these plans in 2025. The Exchange noted that this market exit coincided with the expansion of hardship exemption eligibility guidance released by HHS in September 2025, and that carriers indicated these plans were financially unsustainable under the expanded eligibility framework. The State Exchange stated that it will be able to resume offering catastrophic plans if any carriers choose to do so in the future, and that it and the State insurance regulator intend to proactively seek information from carriers to determine whether future plan designs or revised market conditions may alter their interest in offering catastrophic plans. The State Exchange also noted that the proposed multi-year catastrophic plan structure would present significant implementation and technical challenges.

Other commenters noted concerns about the operational challenges created by the rulemaking timeline relative to State rate filing deadlines. A few commenters requested CMS to delay the implementation date to PY 2028 or later, arguing that by the time the final rule is published, it will be too late for carriers to update rates for PY 2027. Additional commenters noted broader State authority and preemption concerns and noted that the 30-day comment period was insufficient for a proposed rule of this scope and complexity.

Response: We acknowledge the important role that States play in operating and enforcing their Exchanges and related requirements. This final rule does not preempt State authority under section 1321 of the Affordable Care Act, which provides States flexibility in the operation and enforcement of Exchanges and related requirements.\213\ States retain discretion to determine how to operationalize this policy within their existing systems.

\213\ See 42 U.S.C. 18041(d) (preserving State regulatory authority where State law does not conflict with Federal requirements).

For States that enforce their own individual mandates or process their own hardship exemptions, this final rule establishes a Federal floor for hardship exemption eligibility that applies to consumers in all States. States that independently process exemptions may implement the expanded criteria within their existing systems. States that prefer to delegate exemption processing to HHS may do so. We will provide technical assistance to support implementation and ensure that States can exercise this flexibility while maintaining consistent consumer protections nationwide. Unlike regulatory actions that reduce coverage and predictably increase uncompensated care burdens, this rule expands coverage options for individuals who would otherwise be uninsured, reducing--not increasing--the fiscal burden on safety-net providers. Any claim that this rule harms community health centers would require speculation about individual consumer choices that are not traceable to this rulemaking.

For the request that States that enforce their own individual mandates or process their own hardship exemptions retain sole discretion to determine the scope of their hardship exemptions and be exempted from any requirement to broaden hardship exemption eligibility for catastrophic coverage, we decline to adopt this approach. We believe it is an important policy that all consumers--regardless of the State in which they reside--have access to the hardship exemption eligibility criteria established under Federal law, including the expanded criteria codified in this final rule. Consistent with the structure of the Exchange program, this final rule establishes a Federal floor for hardship exemption eligibility. States that independently process exemptions may implement the expanded criteria within their existing systems; States that prefer to delegate exemption processing to HHS may do so. We do not believe it would be appropriate to allow States to

narrow the scope of Federal hardship exemption eligibility for their residents, as doing so would create inconsistent consumer protections across States and undermine the uniform access to catastrophic coverage that this rule is designed to provide. Section 1321 of the Affordable Care Act provides States flexibility in the operation of their Exchanges, but we do not believe that flexibility extends to narrowing the eligibility criteria for catastrophic coverage under section 1302(e) of the Affordable Care Act or exempting residents from the hardship exemption standards established under section 5000A(e)(5) of the Code.

States that have enacted their own individual mandate laws retain sole discretion to determine the scope of hardship exemptions for purposes of their own State mandate penalties--but that discretion is separate from, and does not affect, the hardship exemption criteria under section 5000A(e)(5) of the Code and section 1302(e) of the Affordable Care Act that govern eligibility for catastrophic coverage.

We acknowledge the report that no carriers currently offer catastrophic plans through one State Exchange and that the on-exchange market withdrawal coincided with the September 2025 guidance. Carrier participation decisions are made independently by issuers based on their own actuarial and business assessments, and the availability of catastrophic plans on any given Exchange is subject to issuer participation choices that are outside our direct control. We will monitor carrier participation trends in catastrophic plan markets and will consider whether additional regulatory or sub-regulatory action is warranted to support issuer participation and market stability.

For the implementation timeline and rate filing deadline concerns, we note that the expanded hardship exemption guidance underlying this codification was issued on September 4, 2025--well in advance of the PY 2027 rate filing cycle--and that the streamlined online application process launched November 1, 2025.\214\ Issuers therefore have the opportunity to account for the expanded eligibility in their PY 2027 rate submissions. Because this final rule codifies guidance that has been in effect since November 1, 2025--the start of the 2026 Open Enrollment Period--issuers filing 2027 rates during the standard rate review period were able to draw on actual 2026 enrollment experience under the expanded eligibility when developing their rate submissions.\215\ The 2026 enrollment data demonstrate that catastrophic plan uptake under the expanded eligibility was increased but overall still a small part of the overall market, with only 67,489 consumers selecting a catastrophic plan out of 23.1 million total plan selections,\216\ which is consistent with the risk pool assumptions underlying 2027 rate submissions. We therefore do not anticipate that codification of this guidance will materially disrupt PY 2027 rate filings for this provision specifically. We acknowledge that other novel catastrophic plan proposals finalized in this rule--including multi-year plan terms and cost-sharing modifications--present more complex pricing considerations, which are addressed in the relevant sections of this final rule.

\214\ CMS, Expanding Access to Health Insurance available at https://www.cms.gov/newsroom/fact-sheets/expanding-access-health-insurance-consumers-gain-access-catastrophic-health-insurance-plans-2026.

\215\ See CMS. 2026 Rate Review Timeline Bulletin (describing the standard rate filing and review schedule for plan year 2027), available at https://www.cms.gov/files/document/2026-rate-review-timeline-bulletin.pdf.

\216\ CMS. 2026 Marketplace Open Enrollment Period Public Use Files, available at https://www.cms.gov/data-research/statistics-trends-reports/marketplace-products/2026-marketplace-open-enrollment-period-public-use-files.

We acknowledge that the interaction between this provision and other proposed changes to catastrophic coverage may present additional actuarial complexity for issuers; those interactions are addressed in the relevant sections of this final rule. We will work with States and issuers to facilitate timely and effective implementation and will provide additional operational guidance as needed.

For the comment period length, we note that the proposed rule was published in the Federal Register on February 11, 2026, with a comment period consistent with applicable APA requirements.\217\ We carefully considered all comments received and have addressed the substantive concerns raised in this final rule.

\217\ See 91 FR 6292 (Feb. 11, 2026) (establishing comment period).

Comment: Commenters stated that the hardship exemption expansion is premature and that CMS lacks sufficient data to evaluate its impact before codifying and further expanding the policy. Commenters noted that the expanded hardship exemption has been in effect for only one enrollment period--since September 2025--and that issuers need additional enrollment experience to develop actuarially sound pricing for catastrophic plans. Commenters requested CMS not to build additional policy structures on top of an exemption whose scope and market impact remain untested and recommended that CMS conduct and publish an actuarial analysis quantifying the projected impact on Exchange risk pools, premiums, and Federal subsidy costs before implementation. Commenters also requested gathering additional data and interested parties' feedback before finalizing the interaction between the expanded hardship exemption and other proposed changes to catastrophic coverage, including multi-year plan terms and cost-sharing modifications.

Response: We acknowledge that the expanded hardship exemption, first established through HHS guidance issued on September 4, 2025, has been in effect for a limited period and that complete enrollment data for PY 2026 is not yet available. The underlying hardship challenge driving this policy, however, is well-documented and does not require additional enrollment data to justify action. Sustained, market-wide premium increases--a 219 percent cumulative increase from 2013 to 2026, including a 26 percent increase in 2026 alone, far outpacing inflation (39 percent) and wage growth (53 percent) over the same period,--have created a structural barrier to obtaining coverage for individuals who cannot access APTC or CSRs to offset those costs. For individuals with household income below 100 percent of the FPL or above 400 percent of the FPL who are ineligible for APTC, this premium growth represents a direct and unmitigated barrier to coverage. For individuals between 250 percent and 400 percent of the FPL who are eligible for APTC but ineligible for CSR, the full cost-sharing burden of metal-level plans represent a distinct but related barrier to the capability to obtain coverage under a qualified health plan. While these individuals may reduce their premium through APTC, they remain ineligible for cost- sharing reductions (CSR), which substantially reduce deductibles, copayments, and out-of-pocket maximums for silver-level plan enrollees--in some cases increasing the effective actuarial value of a silver plan from 70 percent to as high as 94 percent. Without CSRs, these individuals face the full cost-sharing burden of metal-level plans, which may render coverage financially inaccessible as a practical matter even where a premium subsidy is available. The Secretary has determined that these circumstances constitute a qualifying hardship for the capability to obtain coverage under section 5000A(e)(5) of the Code--a

determination grounded in the documented, market-wide divergence between premium costs and the financial resources available to this population.

We acknowledge that commenters have raised a policy concern--not a statutory one--about whether we should gather additional enrollment data before codifying and expanding the hardship exemption. We decline to delay finalizing this policy for that purpose for the following reasons. First, the underlying hardship driving this policy is well- documented through existing market data, including the sustained, market-wide premium increases described above, and does not require enrollment data from the expanded eligibility period to establish a sufficient evidentiary basis for action. Second, the September 4, 2025, guidance has been in effect since November 1, 2025, and delaying codification would create regulatory uncertainty for consumers and issuers who have been operating under the expanded eligibility for the duration of the 2026 Open Enrollment Period. Third, the enrollment data that is available--including the 2026 Open Enrollment Period data discussed above--demonstrates that the policy has had minimal market impact, which is consistent with the risk pool assumptions underlying this rule. Finally, we are committed to ongoing monitoring of enrollment trends and market conditions and will consider corrective regulatory action in future rulemaking if monitoring data reveals material harm. This monitoring commitment is the appropriate mechanism for addressing data gaps--not delaying a rule that addresses a present and ongoing hardship.

As previously discussed, the population facing these the income specific circumstances constitute a qualifying hardship with respect to the capability to obtain coverage under section 5000A(e)(5) of the Code and warrant a timely policy response. We will continue to monitor enrollment trends and market conditions as data from PY 2026 becomes available and will transparently report on the impact of the expanded eligibility on risk pools, premiums, and the health care needs of enrollees in catastrophic plans, to the extent such data is available through existing CMS data systems and reporting mechanisms. We are committed to considering corrective regulatory action in future rulemaking if monitoring data reveals material harm. Concerns about actuarial pricing, product design, and the interaction with other catastrophic coverage proposals--including multi-year catastrophic plan terms, cost-sharing modifications, plan-level adjustments, and risk adjustment methodology--are addressed in sections III.E.2. (Sec. 156.80(d)(2)(ii)), III.E.6 (Sec. 156.155(a)(6)), and III.E.7. (Sec. 156.155(a)(3)) of this final rule.

Comment: At least one commenter stated support for the hardship exemption expansion, noting that it presents an opportunity to reconsider how individual market coverage can function within defined- contribution employer models such as ICHRAs. The commenter described a two-layer healthcare strategy in which employees enroll in an affordable bronze or catastrophic Affordable Care Act plan--funded primarily with employer-provided ICHRA dollars--as protection for major medical events, while supplementing that coverage with an HSA savings strategy for everyday health care needs.

Response: We appreciate the commenter's perspective on the interaction between the hardship exemption expansion and the ICHRA framework. We agree that the expanded hardship exemption, combined with the existing eligibility of catastrophic plans for HSA pairing, may create new opportunities for consumers and employers to design coverage strategies that balance premium affordability with protection against major medical expenses. Consumers participating in ICHRAs who qualify for the hardship exemption under Sec. 155.605(d)(1) will be able to use their ICHRA funds toward catastrophic plan premiums, consistent with applicable ICHRA rules,\218\ and may also contribute to an HSA if their ICHRA is an HSA-compatible ICHRA and they are otherwise eligible to contribute to an HSA.\219\

\218\ See 26 CFR 1.105-2; Individual Coverage Health Reimbursement Arrangements, 84 FR 28888 (June 20, 2019).

\219\ See IRS Notice 2026-5, Q&A 5, available at https://www.irs.gov/pub/irs-drop/n-26-05.pdf.

We note, however, that consumers considering this strategy should carefully evaluate whether a catastrophic plan meets their individual health care needs--particularly those with ongoing or complex health care needs who may face significant out-of-pocket spending before the deductible is met.

Comment: Commenters noted concerns about the adequacy of consumer disclosures for catastrophic plans, particularly for populations with limited health insurance literacy, reduced access to enrollment assistance, or challenges navigating digital-first enrollment systems. Commenters noted that these populations may not fully understand how catastrophic plan deductibles, cost-sharing, and pre-deductible limits operate in practice, increasing the likelihood that they will delay or forgo care and encounter access barriers only after a health need arises. Commenters requested that CMS require issuers to provide robust, plain-language consumer disclosures that accurately describe how catastrophic coverage functions in practice, including covered benefits, deductibles, cost-sharing, and pre-deductible services. Commenters also requested CMS to incorporate information about these Exchange policy changes into Navigator and Outreach & Enrollment (O&E) staff training curricula to ensure that assisters--including those serving Community Health Center (CHC) patient populations--are equipped to provide clear, accurate, and timely information to consumers.

Response: We appreciate these commenters' emphasis on the importance of plain-language consumer disclosures and assister training, and we share their commitment to ensure that consumers have the information they need to make informed coverage decisions.

Plain-Language Disclosure Requirements: We and issuers are already subject to robust plain-language requirements under both Federal law and the Affordable Care Act. Under the Plain Writing Act of 2010, Federal agencies are required to use clear communication that the public can understand and use, and agencies are required to submit annual compliance reports on each agency's plain language web page.\220\ We recognize that plain language is especially important in the context of health care services, where clear, concise, and jargon- free communication helps address the needs of those with limited literacy or limited health literacy skills. In addition, the Affordable Care Act requires all health plans and issuers to provide consumers with a Summary of Benefits and Coverage (SBC)--a short, easy-to- understand document written in plain language and in a standard format--at key points in the enrollment process, including upon application and at renewal.\221\ The SBC includes standardized coverage examples and is accompanied by a uniform glossary of commonly used health insurance terms. These requirements apply to

catastrophic plans. Consistent with Sec. 147.200, issuers are required to provide consumers with an SBC at key points in the enrollment process--including upon application and at renewal--and the SBC must be made available to consumers upon request at any time. For multi-year catastrophic plans, consistent with the framework described in section III.E.6. of this final rule (Sec. 156.155(a)(6)), the SBC must be provided upon initial enrollment in the multi-year term. Because multi- year catastrophic plans do not have a renewal date until the expiration of the multi-year term, the SBC renewal trigger under Sec. 147.200 would not apply within the multi-year term itself--it would apply at the end of the term, when the enrollee's coverage is renewed for a new term. Issuers of multi-year catastrophic plans must also make the SBC available upon request at any time during the multi-year term, consistent with the general requirements of Sec. 147.200. In the individual market, the SBC accessible to consumers during the plan comparison and selection process; consumers may also request the SBC at any time and must receive it within seven business days of the request. Under Sec. 147.200(a)(2), the SBC must include the plan's cost-sharing provisions--including the deductible, coinsurance and cost-sharing obligations--and coverage examples illustrating how the plan covers care in common medical scenarios, helping consumers understand their potential out-of-pocket costs.

\220\ Plain Writing Act of 2010, Public Law 111-274, 124 Stat. 2861 (Oct. 13, 2010). HHS' annual plain writing compliance reports are available at https://www.hhs.gov/open/plain-writing/index.html.

\221\ See 45 CFR 147.200 and 156.220 (Summary of Benefits and Coverage requirements).

We conclude that the existing SBC requirements, together with the HealthCare.gov consumer education resources and assister training in this final rule, provide a sufficient framework for ensuring that consumers enrolling in catastrophic plans have access to clear, accurate, and comparable information about their coverage. We are not finalizing additional disclosure requirements specific to catastrophic plans in this rule. We will, however, monitor consumer comprehension and enrollment outcomes under the expanded hardship exemption eligibility and will consider whether additional plan-specific disclosure requirements--including disclosures targeted to consumers with chronic conditions or complex health care needs--are warranted through future notice-and-comment rulemaking.

Existing HealthCare.gov Consumer Education Resources: We maintain robust plain-language consumer education resources on HealthCare.gov specifically designed to help consumers understand and compare their coverage options, including catastrophic plans. These resources include:

A dedicated Catastrophic Health Plans page that clearly notes who qualifies for catastrophic coverage, and what these plans cover. The page describes the pre-deductible benefits--preventive services at no cost, at least three primary care visits per year before the deductible, and notes that all 10 EHBs are covered but are subject to the plan deductible. The pages also directs consumers who qualify for APTC or CSR to compare bronze and silver plans before selecting a catastrophic plan.\222\

\222\ HealthCare.gov, Catastrophic Health Plans, available at https://www.healthcare.gov/choose-a-plan/catastrophic-health-plans/.

A Health Plan Categories page that presents a plain- language comparison of bronze, silver, gold, platinum, and catastrophic plan categories, including estimated cost-sharing percentages, deductible levels, and guidance on HSA eligibility for bronze and catastrophic plans.\223\

\223\ HealthCare.gov, Health Plan Categories: Bronze, Silver, Gold & Platinum, available at https://www.healthcare.gov/choose-a-plan/plans-categories/.

A “What Marketplace Health Insurance Plans Cover” page that describes the 10 EHBs required of all Marketplace plans and notes that adult dental and vision coverage are not EHBs--directly addressing the dental coverage gap concern raised by commenters.\224\

\224\ HealthCare.gov, What Marketplace Health Insurance Plans Cover, available at https://www.healthcare.gov/coverage/.

A plan comparison tool that presents consumers with personalized eligibility information, estimated costs after tax credits, and side-by-side plan comparisons.

We recognize that the adequacy of consumer disclosures is particularly important for populations with limited health insurance literacy, reduced access to enrollment assistance, or challenges navigating digital-first enrollment systems. For these consumers, the existing disclosure framework provides meaningful protections. As previously described, issuers are required under Sec. 147.200 to make the SBC available at key points in the enrollment process, including upon application and at renewal, and upon request. The SBC provides standardized, plain language information about the plan's cost-sharing provisions, covered benefits, and coverage examples. Navigators, Certified Application Counselors (CACs), and other assisters also play a critical role in supplementing these disclosures--particularly for consumers who may not fully understand how catastrophic plan deductibles, cost-sharing, and pre-deductible limits operate in practice. As previously discussed, we will ensure that updated assister training materials address the specific needs of these populations, including guidance on how to walk consumers through the SBC, explain the practical implications of catastrophic plan cost-sharing, and help consumers understand when a metal-level plan may better serve their health care needs.

Agent, Broker, Web-Broker, Navigator, and Assister Training: We provide robust and ongoing training, resources, and technical support to agents, brokers, and web-brokers as well as Navigators, CACs, and other assisters throughout the plan year. PY 2026 Marketplace registration and training--available in both English and Spanish--is, at the time of publication of this final rule, live for new and returning agents, brokers, and web-brokers on the MLMS.\225\ We also host ongoing webinars and office hours throughout the year. Information on upcoming training events, topics and registration is available on CMS.gov via REGTAP.\226\ Additional support resources for agents, brokers, and web-brokers--including a dedicated FAQ website, a Video Learning Center, a library of guidance documents, newsletters, and quick reference guides, and access to Marketplace Help Desks--are available on the Agent and Broker Resources website. For Navigators, CACs, and other in-person assisters, PY 2026 FFE Assister Certification Training--including Navigator and CAC training courses and microlearning modules--is available through the CMS Training for Navigators, Agents, Brokers, and Other Assisters page. CMS also provides assisters with access to the Assister Support Hub, which serves as a centralized portal for training, help desk contacts, enrollment applications, and other operational resources. Outreach and enrollment resources--including partner toolkits, multilingual consumer materials in languages including Arabic, Chinese, French, Russian, and Vietnamese, and materials tailored to special populations--are available on the In-Person Assisters page on CMS.gov. Before and during the 2026 open enrollment, which began on November 1, 2025, we provided training and resources to agents, brokers,

assisters, and navigators specifically addressing the expansion of hardship exemption eligibility, including guidance on how to explain the differences between catastrophic and metal-level plans and the circumstances under which consumers may benefit from--or should carefully consider alternatives to--catastrophic plan enrollment. We will continue to provide updated training materials, resources, and office hours to support assisters as this policy is codified and implemented for the upcoming open enrollment in November 2026 and future years.

\225\ CMS, Registration and Training for Marketplace Agents and Brokers, available at https://www.cms.gov/marketplace/agents-brokers/registration-training.

\226\ CMS, Resources for Agents and Brokers, available at https://www.cms.gov/marketplace/agents-brokers/resources.

We agree that assisters play a critical role in helping consumers-- particularly those with chronic health conditions who may have complex health care needs or limited health insurance literacy--make informed enrollment decisions. We will ensure that updated Navigator and open enrollment training curricula reflect the expanded hardship exemption eligibility, the coverage characteristics and cost-sharing obligations of catastrophic plans, the absence of dental benefits in catastrophic plans, and the importance of helping consumers understand how their APTC, PTC, and CSR eligibility interacts with their plan choices.\227\ We will also ensure that training materials address the specific needs of chronic health condition patient populations, including individuals managing chronic conditions or multiple comorbidities for whom catastrophic coverage may not be the most appropriate option.

\227\ CMS, Training for Navigators, Agents, Brokers, and Other Assisters, available at https://www.cms.gov/marketplace/resources/training.