Each year, CMS releases the Notice of Benefit and Payment Parameters (NBPP), setting the regulatory framework for ACA plan issuers. The 2026 NBPP brings changes that will impact plan design, state-based marketplace transitions, actuarial value (AV) calculations, and more.

In this episode of Regulatory Joe, we’re breaking down five of the biggest regulatory updates from the 2026 NBPP and what issuers need to do now to stay ahead.

NBPP Regulatory Update 1: CMS Moves to a Single AV Calculator

For years, issuers have had to deal with multiple AV Calculator updates throughout the filing season. Each update meant recalculating plans, making last-minute adjustments and scrambling to remain compliant across different metallic tiers.

In the 2026 NBPP, CMS has confirmed that there will be only one version of the AV Calculator this year. This eliminates the risk of unexpected mid-season updates, giving issuers the ability to finalize plan designs without worrying about sudden recalibration requirements.

While this simplifies the process, it also means issuers must get their calculations right from the start. With no second chances to adjust for regulatory shifts, plan modeling needs to be precise from day one.

Regulatory Joe Recommendations

• Run AV calculations early using the final AV Calculator and CMS’s standard plan design options.
• Maintain a version-controlled system to track cost-sharing changes.
• Reduce reliance on mid-season recalculations by implementing internal benchmarks for AV modeling efficiency.

NBPP Regulatory Update 2: More State Control Over ACA Marketplaces

The shift from federally facilitated marketplaces (FFMs) to state-based marketplaces (SBMs) continues, with CMS giving states more authority over plan design mandates, cost-sharing limits, formulary requirements and pricing models.

This means issues operating in multiple states must prepare for greater regulatory variation. Policies that were once uniform across federal marketplaces may now differ depending on state-specific mandates. Some states will impose stricter benefit requirements, while others may introduce new user fees that affect pricing strategies.

Regulatory Joe Recommendations

• Establish relationships with state regulators to track marketplace transition and new policy mandates.
• Prepare for potential cost increases in states moving to SBMs, as user fees may vary.
• Model multiple pricing scenarios to account for state-imposed changes in plan design and cost-sharing requirements.

NPBB Regulatory Update 3: Tighter Income Verification for APTC Eligibility

For Open Enrollment 2026, CMS is tightening income verification rules for Advanced Premium Tax Credits (APTCs). This translates into stricter enforcement of Federal Poverty Level (FLP) thresholds, requiring more precise verification during the enrollment process.

The implications are significant: if an issuer miscalculates subsidy eligibility, it could lead to incorrect premium estimates, enrollment disruptions and compliance risks. Members may also see unexpected changes in their tax credits, leading to potential dissatisfaction or coverage lapses.

Regulatory Joe Recommendations

• Conduct pre-enrollment eligibility tests using Direct Enrollment (DE) or Enhanced Direct Enrollment (EDE) systems.
• Use real-world member profiles (e.g., a 40-year-old, non-smoker with dependents) to validate pricing accuracy.
• Monitor how state-based exchanges handle income verification differently from healthcare.gov.

NBPP Regulatory Update 4: New Call Center Performance Standards

As ACA enrollment grows—surpassing 21 million members—CMS is raising the bar on call center performance standards. The 2026 NBPP introduces stricter guidelines for response times, wait times and reporting metrics.

Issuers can expect more transparency in CMS’s call center reports, providing greater insight into call handling efficiency. While this benefits consumer experience, it also puts pressure on issuers to improve staffing and service operations.

Regulatory Joe Recommendations

• Forecast call volume increases based on rising ACA enrollment trends.
• Evaluate whether to expand internal call center capabilities or contract with an external provider.
• Monitor CMS reporting metrics to ensure compliance with response time and service level benchmarks.

NBPP Regulatory Update 5: Expanded Access to Special Enrollment Periods

CMS is expanding its policy on year-round Special Enrollment Periods (SEPs) for low-income individuals, reinforcing a trend toward greater enrollment flexibility.

Individuals with household incomes at or below 150% of the Federal Poverty Level (FPL) will qualify for monthly enrollment opportunities, allowing them to sign up for coverage outside of the standard open enrollment period. While the SEP was previously tied to enhanced subsidies under the American Rescue Plan and Inflation Reduction Act, the 2026 rule formalizes and strengthens its availability moving forward.

While this change benefits members by increasing access, it also means issuers must stay aware of how CMS and individual states are handling SEP eligibility and subsidy application. As states adjust their policies, issuers will need to track differences in implementation between federal and state-based exchanges to ensure compliance and accurate pricing.

Regulatory Joe Recommendations

• Monitor state-level SEP policies, as some states are adjusting subsidy application rules.
• Track enrollment trends to assess the impact on plan participation and pricing.
• Ensure internal teams are aligned on how CMS’s SEP updates affect eligibility and compliance.

NBPP 2026 Recap: What Issuers Should Do Now

With the 2026 NBPP finalized, issuers have a limited window before key plan filing deadlines in mid-2025 to analyze changes and adjust strategies. The earlier release gives issuers more time than in previous years, but that time must be used wisely to ensure compliance and optimize plan design.

The most immediate priorities for issuers include:

• Reviewing the final rule to identify which updates will impact plan pricing, design and compliance requirements.
• Engaging with state regulators early to anticipate state-based marketplace transitions and evolving SEP policies.
• Refining operational processes to ensure AV calculations, call center performance and income verification procedures align with new CMS requirements.

By acting now, issuers can stay ahead of regulatory shifts, reduce compliance risks and maintain a strong competitive position in the evolving ACA market.

Be sure to watch the full episode for a more detailed run-down of changes and recommendations.

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VIDEO TRANSCRIPT

[00:00:00] Hey, everybody. Welcome to Regulatory Joe. I’m Joe Boyle, President of Regulatory Solutions here at Penstock. On today’s episode, we’ll be discussing the Notice of Benefit and Payment Parameters for Plan Year 2026 and everything you need to know.

 The NBPP at baseline is a multi-hundred page policy document released by CMS each year. It touches on all the core fundamental components of the Affordable Care Act and outlines all the programmatic requirements that issuers must follow to be successful and compliant to serve their members in the future upcoming plan year.

They collect feedback for performance from all plan issuers for the previous past plan year. They evaluate feedback through quality star ratings, through public comment periods from issuers in the general public, and formulate an opinion where they actually publish this final rule.

For the past many years, CMS has actually delayed the release of the NBPP in its final state until as late as February of each calendar year. This past plan year, CMS has actually pushed that date up where they released the draft document in [00:01:00] November of last year and they’ve actually released the final version around the January 15th timeframe of 2025.

It’s important to call out that that is the earliest CMS has actually published the final rule ever since the inception of the ACA. This is favorable to issuers because it allows us more time to review and ingest the documentation with all the proposed changes, as well as evaluating impact to plan portfolio strategy and analysis.

 We have seen a common theme of certain focus areas that continue to be strengthened by CMS. A couple of these key topics include the AV calculator, special enrollment periods, such things as strengthening network adequacy requirements and even standard plan and non-standard plan options.

While it is clear that CMS continues to repeat topics year over year, they are strengthening certain things that can be favorable for issuers for plan year 2026: increasing speed to market, increasing efficiencies in the systems that we use, such as SERFF, HIOS and MPMS.

So that being said, let’s talk about some key [00:02:00] updates for the NBPP for plan year 2026.

AV CALCULATOR

If you did listen in to a few of our most recent episodes, we did have a spotlight on AVs, and specifically for Plan Year 2026. The big change is there will only be one single version of the AV calculator and AV methodology published for this year. And you may think it’s crazy, but in prior years, if you were actually close to the work running AVs for different metallic tiers, for your bronze, expanded bronze, silver, platinum or gold plans, you may have realized that CMS actually published new versions mid-cycle within filing season.

Now that’s a problem because you can run AVs all day long and make sure that you’re compliant with all your metallic tiers, but once CMS releases that new version of the calculator, you have to rerun all your plans. Whether you have one plan, five plans or, even with your variants, could be up to a couple hundred plans.

We did see issuers with a mad dash and a scramble to reconcile plans that may have fell out of compliance. But the good news is that the AV calculator was released [00:03:00] in tandem with the final NBPP for plan year 2026. There’s no more waiting for that final calculator. And even when the draft was released, last November, issuers should have been running that draft to actually plan for their portfolio strategy anyways.

We do know that some issuers are just starting their plan portfolio strategies as states are releasing their new plan guidance, but what we do know is that, look in the NBPP, find CMS’s standard plan design options, pull those out of the appendix, probably appendix C or D, and use those plan cost shares and copays to input in your AV calculator to get a head start.

Even if you don’t know where your plan’s going, what your leadership team needs to do to increase membership or lower their cost position, you can still model some plan designs, make some recommendations to the business and get ahead of decision-making.

It’s important to track the versions of your cost shares and copays as you’re running them through the tool. For example, if you’re changing a PCP copay from $10 to $20, [00:04:00] make sure you flag that change and make a comment and note of when it changed, what version of the document has changed and the outputs for the AV results and save those in a separate folder.

It’s going to be really important to have versioning control and continuity for your data, or else it’s going to get really messy and hard to keep track of. Make sure you keep a changelog as well, because what you can actually derive from the AV calculator is a lot of metrics. So making sure that you can actually set goals and benchmarks for next year that says okay, I ran the calculator X amount of times. We’re going to reduce that by half in year two, reduce that by three quarters in year three.

SBM/SBM-FPs

Another topic CMS put emphasis on for Plan Year 2026 is state-based marketplaces operating on the federal platform, also known as SBM-FPs.

As we see the ongoing trend of states transitioning to SBMs, retaining more control over their state policies for ACA plan filings year over year, we can actually anticipate that CMS will continue to strengthen the impact on state-based marketplaces, possibly even [00:05:00] extending the transition period for greater than one year for states that must be operating on the federal platform before they transition to the state-based platform standalone.

For plan year 2026, we do see CMS providing states with more control during the SBM-FP transition process.

What that means is that states are given more control to create new policies and procedures, new requirements for issuers to deploy for the new plan year. Some of these changes could be new value-based insurance design programs, new plan design requirements, caps on cost shares and copays or even drug and formulary requirements.

While we do see that states having more control is generally more favorable for members and their health outcomes, we do see that this will come at a greater expense to issuers in the long run.

Understanding the user fees of an SBM-FP versus an FFM will be very important with how you conduct your operations. Working with your states and the regulators day-to-day is going to also be important on how you price your plans.

As a lot of the analysis and interpretation of some of the final rule is still [00:06:00] underway, it’s going to be really hard to actually have one finite solution for your plan strategy for this year. We recommend making about three or four portfolio strategies based on some of the implications that we think will impact your plan for the user fees, the actual conversion of state-based marketplaces on the federal platform, and other state-mandated implications and policies that will be released over the course of February and March prior to your plan filing season.

 If your team doesn’t know where to begin in terms of initial analyses, a couple places where you can start is evaluating the user fees a little bit further. So yes, while we understand that a conversion from a federal marketplace to a state-based marketplace state could yield higher user fees, please make sure you include that in your pricing modeling for your planned premiums.

But then also be mindful as you’re adjusting your plan premiums to account for the user fees on the state-based marketplace federal platform. Please also make sure that you’re adjusting the cost shares and copays that go alongside that.

Income Verification

Another [00:07:00] critical update CMS is enforcing in the 2026 NBPP is income verification during the eligibility and enrollment process. It will be important for your core team to understand, for plan year 2026, the general structure and overall theme of how federal poverty level percentages and APTCs work. Come 11/1, later this year, when members enroll into their system and input their income eligibility and verification information, that could actually change how their APTCs apply to their planned premiums for next year.

The big change here and the big difference that you need to be mindful of is that CMS inherently dictates the Federal Poverty Level Percentage Schedule and income verification in the eligibility application hosted on healthcare.gov.

Specifically speaking, CMS will be incorporating different components into the eligibility validation when members input their household income on healthcare.gov within their application. What we recommend is that issuers prior to 11/1 enrollment [00:08:00] actually can create an account using your enrollment partner, whether it’s using Enhanced Direct Enrollment or Direct Enrollment to actually test eligibility and test income thresholds before members even get a chance to apply for coverage.

The big problem that you want to avoid is that if a member, whether it’s an existing member or a renewing member, is actually applying for coverage at your plan again for a second year, third year or fourth year, the last thing you want to do is to produce incorrect values or incorrect premium dollar amounts on the shopping experience for your members.

We recommend creating a subset of scenarios. We generally use your average 40 year old, non smoker, whether it’s a male or female with one or more dependents, to test eligibility validation. The purpose of this exercise is really just to validate the methodology that CMS has updated during the application process. The last thing you want to do is lose a member based on incorrect information coming through on your federal application or even on a state-based exchange application.

Call Center Standards

 Regardless of the type of exchange that you participate in, whether it’s an [00:09:00] FFM or SBM, it’s really important to understand what CMS is changing for call center standards and wait times for 2026.

So really evaluating the growth of the ACA over the past number of years, we’ve seen membership grow from a modest 14 million members to 16 and a half million members to over 21 million members for plan year 2026. That being said, as membership is exploding this plan year, that’s a direct correlation to having more calls into the call center.

Now, whether it’s CMS’s call center on healthcare.gov fielding these calls with their agents, or a state-based marketplace fielding those calls day in and day out, standards are changing.

For an example, if you do participate in a state-based marketplace today, you may be used to receiving a level of metrics on a regular basis. We can expect a little bit more transparency from CMS with the Federal Call Center Standards and Reporting for Plan Year 2026. Issuers can expect to receive a greater level of detail in the reports, whether it’s more specifics on call [00:10:00] times, wait time standards, hold times, drop times or even repeat call visits to an agent from a member.

Now what’s really interesting and where it could be a little bit more problematic is specific to new issuers, not existing issuers. And the reason why I’m calling out new market entrants is because when you enter a new marketplace, whether it’s an FFM or an SBM, it’s important to understand the implications of who’s taking the calls and the actual process that takes place.

 Most especially for new issuers, when you actually stand up a process, for example, in a federal marketplace, you either have to build or buy service operations capabilities. That either means you have to contract with a call center outside of your organization to take calls and to ingest that into your organization, or you have to staff up temporary call center agents or full-time call center agents by hiring and onboarding.

With the increase of membership, we encourage you to evaluate your membership projections, staff accordingly based on how many calls you anticipate receiving [00:11:00] and augment your staffing model and org design throughout enrollment season.

SEPs

One of the last topics we wanted to touch on for today is Special Enrollment Periods, or SEPs, and this acronym comes up throughout the year, every year since the inception of the ACA.

The last time we really honed in on this as a topic was during COVID when the pandemic was here. Enrollment was extended for months at a time, well beyond January 15 throughout each plan year and calendar year until the public health emergency was lifted.

 As CMS and each individual state to permanently expand subsidy eligibility, specifically focused on members who are eligible for 150 percent of the poverty level could qualify for special enrollment periods throughout each calendar year, every year with no limitations at all.

So while we agree that’s very favorable for the membership that it impacts, allowing them to enroll at any point throughout the year, it really splits membership into different categories, leaving it unfavorable for the rest of the population.

Really the lesson here is to [00:12:00] understand where you participate today, because understanding that the way CMS looks at APTCs, the expansion of subsidy eligibility and the American Rescue Plan, could be different from some of the state-based exchanges that you participate in today.

We are seeing a trend that even as special enrollment periods are carrying forward with CMS, that certain states are augmenting how they apply subsidies to membership within their state specifically.

Closing

So even if the NBPP is now officially final for Plan Year 2026, the review will still be ongoing.

 I think the major takeaway for all issuers across the country is to simply invest the time with your teams to review the NBPP, disseminate the topics that mean the most to your plan strategy, and implement a workgroup, and just really make this an ongoing process that’s a priority for your organization. And just remember, it’s going to come up the same time later this year.