2027 ACA Marketplace Changes

2027 ACA Marketplace Changes | THI Benefits

Plan year 2027

2027 ACA Marketplace Changes

What is changing for Marketplace, Medicaid and HSA coverage in 2027, how it worked before, and what it means for your coverage and costs.

Showing all 37 changes

Policy area	2027 change	Prior years	What it means for consumers
Subsidies & tax credits 4
Premium Tax Credit Income Eligibility Threshold (400% FPL Limit / Subsidy Cliff) Internal Revenue Service (IRS) / Internal Revenue Code Section 36B Sources1 2 3	Eligibility for the Premium Tax Credit is limited to taxpayers with household income between 100% and 400% of the federal poverty line (FPL). Return to pre-2021 subsidy structure.	For tax years 2021 through 2025, enhanced premium tax credits expanded financial assistance and removed the 400% FPL income cap.	Less generous subsidies for eligible households and higher out-of-pocket net premiums; consumers with household incomes above 400% FPL lose subsidy eligibility entirely, significantly increasing monthly health insurance costs.
Advance Premium Tax Credit (APTC) Excess Repayment Caps Internal Revenue Service (IRS) / Department of the Treasury / 2025 Federal Budget Reconciliation Law ("One Big Beautiful Bill") Sources1 2 3	Income-based repayment caps on excess advance payment of the Premium Tax Credit (APTC) are eliminated; taxpayers must repay the total difference between advance payments and actual allowable credit.	For tax years before 2026 (except 2020), statutory income-based repayment caps limited the amount of excess APTC a taxpayer had to repay if household income was below 400% FPL.	Consumers whose actual income is higher than estimated during enrollment face higher tax liabilities, reduced tax refunds, or significant financial repayments during tax reconciliation.
Marketplace Subsidy & PTC Eligibility for Immigrants One Big Beautiful Bill Act (OBBBA) / CMS / HHS / Working Families Tax Cut (WFTC) Legislation (H.R. 1) Sources4 5 2 6 7	Limits APTC, CSR, and Basic Health Program eligibility strictly to "eligible noncitizens" (permanent residents / green card holders, Cuban-Haitian entrants, and COFA migrants). Mandates verification and removes APTC eligibility for noncitizens with income under 100% FPL who are ineligible for Medicaid due to immigration status. Excludes refugees, asylum recipients, and others with lawful status.	A broad list of lawfully present statuses (work/student visas, refugees, asylees, TPS) qualified for Marketplace subsidies and PTCs since 2014. Lawfully present noncitizens under 100% FPL ineligible for Medicaid could qualify for APTC.	An estimated 1.2 million lawfully present immigrants lose income-based premium tax credits and CSRs, making full-price Marketplace coverage significantly more costly or unaffordable and risking loss of coverage.
Employer Health Coverage Affordability Threshold Internal Revenue Service (IRS) / Revenue Procedure 2025-25 / CMS / HHS / ACA Sources1 10	The threshold percentage used to determine if employer-sponsored coverage is affordable is set between 9.96% and 10.22% of household income for plan years beginning in 2026/2027.	Set at 9.02% in 2025, 8.39% in 2024, 9.12% in 2023, 9.61% in 2022, 9.83% in 2021, and original statutory baseline of 9.5%.	A higher threshold percentage makes employer coverage legally "affordable" at higher employee contribution levels, leaving fewer employees eligible for subsidized Marketplace coverage.
Enrollment & eligibility 5
150% FPL Special Enrollment Period (SEP) CMS / HHS / Working Families Tax Cut (WFTC) Legislation (P.L. 119-21) / H.R. 1 (OBBBA) Sources5 6 8 7	Exchanges are prohibited from offering the continuous low-income Special Enrollment Period (SEP) for individuals with household income below or up to 150% FPL after PY 2026.	Monthly, continuous year-round SEPs were available for low-income consumers with household income up to 150% FPL.	Low-income consumers lose the continuous monthly SEP option, reducing opportunities for unauthorized enrollments and plan switching outside standard enrollment periods.
Pre-Enrollment SEP & Eligibility Verification CMS / HHS (2027 Payment Notice) / 2025 Federal Budget Reconciliation Law / Public Law 119-21 Sources5 2 6 8 9	Reinstates and expands pre-enrollment verification for Special Enrollment Periods on federal platform exchanges, covering at least 75% of new SEP enrollments beyond loss of MEC. New pre-enrollment verification rules set up the framework affecting future renewals.	Pre-enrollment verification for SEPs was limited, less stringent, or stayed/blocked by court order (City of Columbus v. Kennedy).	Ensures consistent eligibility application, prevents improper enrollments, balances risk pools, and increases documentation burdens during enrollment.
Income Verification Rules & Program Integrity CMS / HHS (2027 Payment Notice / 2027 NBPP Proposed Rule) Sources5 6 9 7 3	Permanently requires additional income verification when data sources indicate income <100% FPL or when federal tax data is unavailable, and permanently removes the requirement to accept attestation when IRS returns no data. Re-proposes the Failure to File and Reconcile (FTR) policy.	Previous rules contained "sunset" dates after which Exchanges would accept income attestations when tax data was unavailable. Rules were previously struck down in court.	Protects consumers from surprise tax liabilities and reduces APTC overpayments, but increases administrative documentation burdens on applicants with fluctuating or multiple income sources.
Failure to File and Reconcile (FTR) Rule CMS / HHS (2027 Payment Notice) Source5	For PY 2027, Exchanges on the Federal platform adopt a strict 1-year FTR rule, making tax filers ineligible for APTC if they failed to file and reconcile APTC for a prior year. State Exchanges can adopt in 2027 or 2028.	Current standard operated under a two-year FTR policy prior to determining APTC ineligibility.	Consumers who fail to reconcile prior year APTC on tax returns will lose APTC eligibility faster, preventing the accumulation of tax debt.
Open Enrollment Period Source3	Runs from November 1, 2026, to December 15, 2026, for states using the federal HealthCare.gov platform (state-based Marketplaces may differ). Outside of this window, enrollment requires a qualifying life event.	Enrollment flexibility was broader/less limited in prior years, but has since narrowed.	Shorter window and reduced enrollment flexibility require proactive planning; missing deadlines or voluntarily ending coverage without a qualifying life event prevents enrollment.
Plan options & benefits 7
Standardized Plan Options & Limits CMS / HHS (2027 Payment Notice / 2027 NBPP Proposed Rule) Sources5 6 9 7	Discontinues requirement for FFE and SBE-FP issuers to offer standardized plan options, removes differential display on HealthCare.gov, and eliminates non-standardized plan option limits and exceptions.	Issuers were required to offer standardized plan options and faced limits (e.g., caps of two non-standardized plan designs per metal level) on non-standardized plans.	Enhances issuer flexibility to innovate in plan design and increases consumer choices, though it expands regulatory complexity and potential plan comparison difficulty for consumers.
Catastrophic Plan Terms, Benefits, and Limits CMS / HHS (2027 Payment Notice / 2027 NBPP Proposed Rule), Department of Labor, Department of the Treasury Sources5 8 9 7	Allows catastrophic plans to span up to 10 consecutive plan years without annual re-verification and provide pre-deductible value-based coverage pursuant to federal guidelines. Proposes allowing bronze and catastrophic plans to exceed statutory maximum out-of-pocket limits (MOOP) in PY 2028.	Catastrophic plans were structured on a single plan year basis requiring annual re-verification, with restrictive cost-sharing parameters bounded strictly by ACA statutory MOOP limits.	Improves access to lower-cost, multi-year catastrophic coverage and gives consumers flexibility to tailor coverage, though it may increase out-of-pocket spending limits in future years.
Hardship Exemption Eligibility CMS / HHS (2027 Payment Notice / 2027 NBPP Proposed Rule) Sources5 6 9 7	Expands hardship exemption eligibility nationwide to individuals in any state ineligible for APTC/CSR due to projected household income under 100% or above 250% FPL when experiencing income changes.	Hardship eligibility was previously limited to enrollees under age 30 or specific criteria based on guidance issued Sept 4, 2025, applying to FFE, SBE-FP, and delegated State Exchanges.	Allows affected low-income (<100% FPL) and higher-income (>250% FPL) individuals in all states to enroll in catastrophic coverage if otherwise eligible, improving access to lower-premium coverage.
Cost-Sharing Parameters for Bronze and Catastrophic Plans CMS / HHS (2027 Payment Notice / 2027 NBPP Proposed Rule) Sources5 8 9	Adjusts permissible cost-sharing parameters to increase flexibility for issuers designing individual market bronze plans in PY 2027 (and catastrophic plans in PY 2028).	Previous, more rigid cost-sharing parameters applied to plan designs without these updated flexibility rules.	Gives plan issuers more flexibility in plan design, impacting out-of-pocket costs and benefit structures for bronze and catastrophic health plans.
Essential Health Benefits (EHB) Scope – Routine Adult Dental CMS / HHS (2027 Payment Notice / ACA / 2027 NBPP Proposed Rule) Sources5 6 8 9 7	Prohibits issuers from including routine non-pediatric (adult) dental services as an Essential Health Benefit (EHB). Also requires states starting in 2028 to offset costs for state-required benefits post-2011 beyond ACA EHBs.	Policy finalized in the 2025 Payment Notice under the Biden administration allowed routine adult dental benefits to be included as an EHB.	Routine adult dental care will no longer be covered under federal essential health benefits, aligning EHB scope with typical employer plans and restructuring plan benefit design.
Non-Network Qualified Health Plans CMS / HHS (2027 NBPP Proposed Rule / Notice of Benefit and Payment Parameters for 2027) Sources9 7	Establishes a new pathway allowing non-network plans (plans that do not use a network of providers) to become certified as Qualified Health Plans (QHPs) on exchanges if they demonstrate provider access.	QHPs were required to maintain established provider networks subject to standard time and distance criteria.	Offers new non-network plan options on exchanges, providing additional plan design options but altering how consumers access doctors and medical care.
Alternatives to ACA Marketplace Coverage Trump Administration Source2	Increased facilitation and promotion of short-term limited-duration health plans as alternatives to ACA coverage.	Strict restrictions previously limited the duration and availability of short-term plans.	Consumers can access non-ACA plans, but these plans can reject individuals based on medical history and are not eligible for ACA premium tax credits, leaving consumers to pay full cost.
Medicaid 4
Medicaid Expansion Eligibility / Work Requirements One Big Beautiful Bill Act (OBBBA) / H.R. 1 Source4	Adults covered under Medicaid expansion will face a work requirement starting January 1, 2027.	Medicaid expansion enrollees (up to 138% FPL) were generally not subject to federal work requirements under the ACA.	Unless enrollees qualify for an exemption, they must comply with work requirements to maintain Medicaid coverage; failure to comply leads to loss of coverage.
Medicaid Redetermination Frequency One Big Beautiful Bill Act (OBBBA) / H.R. 1 Source4	Medicaid expansion enrollees must undergo eligibility redeterminations semi-annually (every 6 months) starting in 2027.	Eligibility redeterminations occurred once per year.	Requires more frequent paperwork and administrative compliance; increases risk of disenrolling eligible consumers due to administrative hurdles.
Retroactive Medicaid Coverage Limits One Big Beautiful Bill Act (OBBBA) / H.R. 1 Source4	Retroactive coverage for unpaid medical bills is capped at 1 month for Medicaid expansion enrollees and 2 months for traditional enrollees starting January 2027.	Most states historically allowed up to 3 months of retroactive Medicaid coverage.	Reduces retroactive financial protection for consumers with unpaid medical bills prior to their application date; individuals must apply as soon as possible.
Federal Medicaid Funding and State Benefits One Big Beautiful Bill Act (OBBBA) / H.R. 1 Source4	New rules starting October 2027 reduce federal Medicaid funding to most states.	Higher baseline federal funding rules/matching without these new OBBBA funding restrictions.	States may cut optional benefits (e.g., dental, vision, therapy, home care) and lower provider reimbursements, reducing consumer access to doctors and services.
Premiums & market rules 8
Marketing Practices Regulations & Agent/Broker Oversight CMS / HHS (2027 Payment Notice / 2027 NBPP Proposed Rule) Sources5 6 9 7	Prohibits practices such as cash/monetary rebates, falsely asserting zero-dollar insurance, and miscommunicating deadlines. Requires agents/brokers to use an HHS-standardized eligibility documentation form and ends HHS vendor training approval.	Less stringent regulations and standardized documentation existed for marketing practices, consumer consent, and eligibility application review by agents, brokers, and web-brokers.	Cracks down on fraud and improper agent/broker enrollments, protecting consumers from misleading zero-dollar claims and unauthorized plan switches.
Premium Payment Thresholds CMS / HHS (2027 Payment Notice) Source5	Permanently rescinds the option for issuers to implement both fixed-dollar and gross percentage-based premium payment thresholds for PY 2027 and beyond.	Issuers were permitted to implement premium payment thresholds.	Ensures consumers are aware of enrollments, prevents improper enrollment without consumer knowledge, and increases transparency.
Exchange User Fees CMS / HHS (2027 Payment Notice / ACA / Notice of Benefit and Payment Parameters for 2027) Sources5 6 9	User fee rates lowered to 1.9% of monthly premiums for FFEs and 1.5% for SBE-FPs for the 2027 benefit year. Risk adjustment user fee reduced to $0.18 PMPM.	User fee rates were higher in benefit year 2026 (2.5% for FFEs and 2.0% for SBE-FPs).	Lower user fees on issuers reduce operational fee burdens, which is intended to help exert downward pressure on consumer premiums.
Quality Improvement Strategy (QIS) Requirements CMS / HHS (2027 Payment Notice / ACA) Source5	Issuers must submit QIS addressing any 2 of 5 ACA topic areas; no longer required to address "health and health care disparities" specifically.	QHP issuers were required to specifically include health and health care disparities as a mandatory topic area.	Allows plans to target quality initiatives to pressing needs of their specific enrollees. Public quality ratings remain unaffected.
Marketplace Plan Premiums and Insurer Participation ACA / Insurers / Market Dynamics Source2	Insurers seek a median premium increase of about 15% for 2027; some plan to leave certain ACA markets due to risk pool deterioration following the expiration of enhanced tax credits.	Record effectuated enrollment reached 21.8 million in 2025 due to enhanced tax credits, but enrollment dropped to 19.2 million in 2026 after enhanced tax credits expired.	Higher total insurance costs; higher-income consumers no longer eligible for subsidies face full rate increases, while healthier enrollees dropping coverage may lead to higher prices and fewer insurer choices.
Cost-Sharing Reduction (CSR) Reporting & Loading CMS / HHS (2027 NBPP Proposed Rule) Source7	Requires insurers using CSR loading to submit past/prospective CSR data; prohibits CSR loading on qualified health plans if Congress appropriates CSR funds directly.	Insurers loaded unfunded CSR costs onto silver plan premiums without specific past/prospective CSR reporting templates.	If CSRs are directly funded by Congress, premium loads on silver plans would be removed, directly lowering gross silver plan premiums.
State Oversight Flexibility & Transitioning CMS / Notice of Benefit and Payment Parameters for 2027 Source9	Allows FFE states meeting federal standards to conduct their own provider access and Essential Community Provider reviews, and removes the transition period for states moving from FFE to State-based Exchange (SBE).	CMS conducted reviews directly for FFE states, and a mandatory transition period existed for states moving from FFE to SBE.	Allows states to tailor reviews to local market conditions and simplifies Exchange transitions.
Rate Filings Transparency CMS / Notice of Benefit and Payment Parameters for 2027 Source9	Requires greater transparency in rate filings, specifically regarding how issuers account for unreimbursed cost-sharing reductions.	Less detailed disclosure required regarding unreimbursed cost-sharing reductions.	Increases transparency around rate calculation and premium pricing factors.
HSA & out-of-pocket limits 9
HSA Contribution Limit (Self-only) IRS / Revenue Procedure 2026-24 Source11	$4,500 (up $100)	$4,400 in 2026	Allows individuals with self-only HDHP coverage to save slightly more pre-tax funds for medical expenses.
HSA Contribution Limit (Family) IRS / Revenue Procedure 2026-24 Source11	$9,000 (up $250)	$8,750 in 2026	Allows families with HDHP coverage to contribute more pre-tax funds toward medical expenses.
HSA Catch-up Contributions (Age 55+) IRS Source11	$1,000	$1,000 in 2026 (No change)	Provides the same additional catch-up savings capacity for consumers aged 55 and older.
HDHP Minimum Deductible (Self-only) IRS / Revenue Procedure 2026-24 Source11	$1,750 (up $50)	$1,700 in 2026	Raises the minimum threshold for a self-only plan to qualify as an HDHP.
HDHP Minimum Deductible (Family) IRS / Revenue Procedure 2026-24 Source11	$3,500 (up $100)	$3,400 in 2026	Raises the minimum deductible threshold required for family plans to be eligible for HSAs.
HDHP Maximum Out-of-Pocket Expense Limit (Self-only) IRS / Revenue Procedure 2026-24 Source11	$8,700 (up $200)	$8,500 in 2026	Increases the annual out-of-pocket spending cap for consumers enrolled in self-only HDHPs.
HDHP Maximum Out-of-Pocket Expense Limit (Family) IRS / Revenue Procedure 2026-24 Source11	$17,400 (up $400)	$17,000 in 2026	Increases the maximum annual out-of-pocket costs for families under HDHP coverage.
ACA Out-of-Pocket Maximum for Essential Health Benefits (Self-only) HHS / ACA Source11	$12,000	Not specified	Sets the highest permissible out-of-pocket cost limit for essential health benefits under non-grandfathered ACA plans for individuals.
ACA Out-of-Pocket Maximum for Essential Health Benefits (Other-than-self-only) HHS / ACA Source11	$24,000	Not specified	Sets the maximum total out-of-pocket limit for non-single coverage under ACA plans.

Sources

Questions and answers on the Premium Tax Credit | Internal Revenue Service
Midterm Election Update: The Affordable Care Act Marketplaces - KFF
ACA Marketplace 2027 Coverage - Modera Wealth Management
One Big Beautiful Bill Act brings sweeping changes to health coverage - Healthinsurance.org
HHS Notice of Benefit and Payment Parameters for 2027 Final Rule | CMS
CMS finalizes ACA marketplace overhaul for 2027: 6 notes - Becker's Payer Issues
CMS Issues Notice of Benefit and Payment Parameters Proposed Rule for 2027 Plan Year - EY – Tax News
3 Ways ACA Marketplaces will Change in 2027 and Beyond - HAP
CMS Final Rule Lowers Costs, Cracks Down on Fraud, and Expands State Control
Affordable coverage - Glossary | HealthCare.gov
On May 29, 2026, the IRS released Revenue Procedure 2026-24 to provide inflation-adjusted limits for health savings accounts (HS - Lawley Insurance

This summary is for general information and is not tax or legal advice. Some items come from proposed rules and may change. Contact THI Benefits to talk through how these changes apply to you.