Agent/broker oversight strengthened in 2026 Marketplace final rule

Are you sick of fraudulent enrollments stealing your clients? So is CMS. On January 13, CMS and the Department of Health and Human Services published the final Marketplace rule for 2026. It does a lot to prevent fraud, make getting and maintaining coverage easier, and bring transparency to the market.

How will the 2026 Marketplace rule impact agents and brokers?

Agents and brokers will immediately see and feel a few impacts.

HHS promises compliance reviews, enforcement actions at the agency level

Throughout 2023 and 2024, CMS received many complaints about unauthorized plan switching. Bad actors exploited security gaps in Enhanced Direct Enrollment pathways and assigned themselves as Agents of Record. Often, they switched unknowing consumers to a more expensive plan, leaving their doctors or drugs uncovered. While several technical steps were taken to reduce fraud, the agency wants to do more.

CMS asserts its authority to review and sanction agencies for noncompliance in this final rule. Principals should take note—CMS will hold lead agents, or the agent whose National Producer Number (NPN) the business is written under, accountable for the entire agency. If CMS finds the lead agent directing, overseeing, or participating in misconduct, it could take enforcement actions. Such actions could include suspension or termination of Exchange agreements and civil fines.

CMS may also suspend agents or agencies from using direct enrollment and enhanced direct enrollment systems. Suspended agents would need to three-way call the Marketplace or enroll the consumer side-by-side on healthcare.gov.

The model consent form gets an update

Two key updates are also coming to the model consent form. First, there will be space for a consumer to document his review of a Marketplace application-- a welcome change for agents and brokers. Second, the form will now include agent scripts to facilitate audio recording of consent and application review. Both steps will make it easier to comply with the rule.

What portions of the Marketplace final rule directly impact consumers?

Consumers will experience changes with premium tax credits, shopping, and enrolling.

Marketplaces must issue file and reconcile notices after two consecutive tax years

Tax filers may not qualify for premium tax credits if they do not file and reconcile for two years in a row. However, CMS previously only required all exchanges, including state-based ones, to notify those failing to file and reconcile after the first year. Now, all Marketplaces must send a notice after the second year, too. Continued failure would make the consumer ineligible for premium tax credits.

Plans can avoid coverage terminations for small premium debts

Consumers receiving large premium tax credits might pay menial premiums. For a variety of reasons, those small amounts may not get paid. And, unpaid premiums have triggered grace periods or coverage terminations.

The final rule establishes two ways insurers can provide flexibility in these cases.

First, insurers can set a fixed-dollar threshold to consider premiums paid in full. As long as the consumer owes less than $10, the carrier can see the premium as paid in full. The second option allows insurers to delay action if they have received 98% of the total premium owed. Both measures make it easier for lower-income consumers to maintain coverage.

Application filers can now make eligibility appeals

Previously, only the application filer and enrollees could appeal a Marketplace’s eligibility determination. That proved difficult for some consumers, especially those for which an assister, agent, or broker applied on their behalf. Beginning in 2026, the application filer may appeal an eligibility determination.

Plan menus see small adjustments

For several years now, CMS has required insurers to provide standardized plan options on the Marketplace. In 2026, slight changes to those plans will keep their actuarial value consistent with the current law.

Additionally, when carriers offer multiple standardized plans at the same tier and in the same area, there must be a meaningful difference between the plans. For example, offering narrow-network plans or formularies designed to treat specific conditions could be allowed.

In 2026, non-standardized plans can include variations covering any combination of adult dental, adult vision, and pediatric dental services. These changes intend to make it easier for consumers to compare and choose plans.

Impacts on the broader market

CMS moves to make the market more transparent.

No movement to address insurer bankruptcies

Over the years, many Marketplace carriers have suddenly gone bankrupt. As they shut down, they leave their former enrollees without coverage. To address this, CMS suggested placing enrollment caps on new carriers based on their financial health. However, the agency declined to act on this rule.

Increased user fees could cause premiums to edge upwards

CMS charges insurers a percentage of monthly premiums to use healthcare.gov for eligibility verification and enrollment.

Due to uncertainty about extending enhanced subsidies, CMS finalized two sets of user fees.

If the enhanced subsidies remain, fees for FFE platforms will climb to 2.2% of the monthly premiums. Insurers in a state-based marketplace using healthcare.gov for eligibility and verification would see user fees increase to 1.8% of the monthly premium.

If enhanced subsidies lapse, user fees would instead climb to 2.5% and 2.0% of monthly premiums, respectively.

Silver loading continues with CMS’s blessing

Since the federal government stopped paying for cost-sharing reductions (CSRs) in 2017, insurers raised premiums on silver plans to offset the cost of CSRs. CMS approves this practice, so long as premium increases are actuarially justified.

Risk-adjustment continues to evolve

CMS operates risk adjustment in every state and currently charges a per member per month rate for this function. For the plan year 2026, this rate will increase to $0.20, two cents higher than proposed. The additional increase offsets the possibility of funding gaps should premium tax credits expire.

CMS will also update risk adjustment models by using data from 2020, 2021, and 2022. Incentives for covering Hepatitis C drugs will also be phased out, bringing their pricing more in line with other specialty drugs. And, to incentivize plans to cover HIV PrEP drugs, these drugs will be included as a separate risk factor in the adult and child models. The move is intended to reduce coverage restrictions and access to care.

State-based exchanges, states performing plan management get closer oversight

CMS is strengthening insurance networks' oversight to ensure enough healthcare providers are serving low-income and underserved communities. This affects health insurance plans sold on the Federal Marketplace in states managing their own plans. The goal is to make sure everyone can access care, regardless of where they live or their income level.

CMS will start sharing more public information about how State Marketplaces operate. This includes how much is spent on outreach, how well their customer service centers perform, and Open Enrollment website performance. And, CMS is setting a new 60-day deadline for State Marketplaces to fix enrollment data errors. This increased transparency builds public trust and keeps these programs running efficiently.

So what?

In short, there are a ton of incremental changes in this rule. Many focus on combatting fraud. Several provisions will help consumers get and keep coverage. And, in what has been a theme for the past several years, CMS is attempting to bring more transparency to Marketplace operations, whether federal or state-based. 

Need help?

Navigating these changes can be complex, but Action Benefits is here to support you. From providing updated documentation templates and compliance training to offering guidance and answering questions that arise, we’re committed to helping you protect your business and serve your clients effectively. Contact your account manager, or get appointed, to get started.