CMS Opens Up Plan Variety: No Provider Network – No Problem – Highlights of 2027 Marketplace Final Rule

Last Friday, the Centers for Medicare and Medicaid Services (CMS) finalized a rule that will implement new policies next year including eligibility restrictions and expanded access to non-traditional health plans.

The rules will allow plans that otherwise would not qualify for the Affordable Care Act’s (ACA) insurance exchange, including health plans with no provider networks and catastrophic plans, which were created for people younger than 30 or experiencing hardship as defined by the ACA. Modern Healthcare explains that people with incomes below the federal poverty level or above 250% of the the line would qualify for catastrophic plans if they are made ineligible for income-based premium subsidies.

The new rule stipulates that states intending to set up new exchanges must operate as a hybrid federal-state marketplace for a year before taking over. Additionally, the rule increases marketing standards including requirements for agents and plan brokers to use standardized eligibility forms and that enrollees must personally affirm the information in applications prepared by third-party marketing organizations (TPMOs). Financial incentives for enrollment will be prohibited and agents are barred from making suggestions that consumers will qualify for free coverage.

As part of its initiative to combat fraud, CMS is reinstating pre-enrollment verification requirements for special enrollment periods that were finalized last year but blocked by a federal court. According to Becker’s, exchanges on the platform will need to verify eligibility before enrollment for 75% of new SEP enrollees.

Some provisions from the One Big Beautiful Bill Act of 2025 (OBBBA) are included in the final rule, including tax credit eligibility narrowing to citizens and a restricted number of immigrants, excluding refugees or asylum seekers.

The CMS Fact Sheet explains that the rule includes civil monetary penalties (CMPs) for noncompliant plans and other responsible entities subject to the new regulations. CMS clarifies that the Department of Health and Human Services (HHS) has the authority to levy CMPs against issuers in state-based exchanges and that HHS may offset payments owed to insurers and affiliated entities under the same tax identification number against outstanding civil monetary penalties and other amounts owed to the agency.

Healthcare affordability advocates Families USA issued a statement shortly after the rule’s finalization, criticizing CMS for further undermining ACA protections and affordability while creating new barriers to insurance coverage. From Families USA director Anthony Wright:

The details of this final rule include allowing even higher deductibles, and to permit plans with no networks. This rule further opens the door to junk plans that leave people unable to access the care they actually need — all while driving up the cost of real, comprehensive coverage for everyone else.