CMS Proposes 2027 ACA Exchange Overhaul – No Adult Dental & ‘Crackdown’ on Waste & High Costs

Early this week, the Centers for Medicare and Medicaid Services (CMS) posted a proposed rule that would overhaul Affordable Care Act (ACA) exchange plan regulations, including ending standardized coverage and broadening access to catastrophic plans.

The rule would repeal a 2023 requirement that federal exchanges and state-based exchanges on the federal platform offer standardized options for gold, silver and bronze level plans. According to Modern Healthcare, the agency also proposed allowing certain non-network plans to attain qualified health plan status if they can demonstrate a sufficient network. It would also allow insurers to offer a “wide array” of catastrophic plans ranging from under a year to a decade in duration and would extend the plans to people who are ineligible for premium tax credits because they make less than the federal poverty line (FPL) or for cost-sharing reductions because they make under 250% FPL.

The proposed rule also includes a continuation of the ongoing crackdown on marketing practices and brokers by including a list of prohibited marketing activities like cash offers, rebates, false assertions of $0 plan qualification and more Inside Health Policy reports. Adult dental services will no longer be allowed to be considered an Essential Health Benefit, CMS argues the policy reversal aligns better with the statute that states EHBs should be equal to those in a typical employer plan, and dental coverage is usually offered as a standalone benefit.

In a CMS press release, Administrator Dr. Mehmet Oz championed the changes as a “crackdown” on waste and high costs:

This proposal puts patients, taxpayers and states first by lowering costs and reinforcing accountability for taxpayer dollars. We are cracking down on improper an misleading practices while giving states and health plans more room to innovate and compete.

Further details on the proposed rule, like changes to certification reviews for Essential Community Providers (ECPs), qualified health plan (QHP) certification of non-network plans and details on new requirements for the risk adjustment program can be reviewed at CMS.