CMS is changing how health plans validate and submit their benefits. Starting in 2026, the Plan and Benefit Justification Form will no longer be uploaded alongside the Plan and Benefit Template. Instead, CMS will generate these forms after submission, directly within the MPMS portal— a shift that changes the timeline for compliance, limits issuer control and could delay plan approvals.

In this episode of Regulatory Joe, we break down the latest CMS changes, their impact on plan submissions, and the best strategies to navigate regulatory filings effectively.

What is the MPMS Plan and Benefit Justification Process?

For years, CMS has published Plan and Benefit Templates and the accompanying Justification Forms on the CMS application webpage. Historically, these documents have been available as a fillable PDF alongside the Excel templates used for plan submissions. However, starting in 2026, issuers will no longer have control over these forms at the time of submission. Instead, CMS will generate Justification Forms post-submission through the MPMS portal.

Key Changes for 2026

• Justification Forms in MPMS: Justification forms are now housed in MPMS rather than being manually uploaded by issuers.
• Limited MPMS Access: Only two users per organization can have access to MPMS.
• Delayed Justification Form Availability: Issuers must now wait for CMS to review plan submissions before justification forms are generated.

How to Prepare for the New MPMS Plan and Benefit Justification Process

While moving Justification Forms into MPMS can enhance CMS’s process standardization, it also shifts the burden of compliance onto issuers post-submission.

This presents potential risks, including:

• Delays in plan approval closer to open enrollment
• Complications in advertising and marketing compliance
• Extended back-and-forth with CMS reviewers

With these updates, issuers need a proactive strategy to ensure a smooth plan submission process and avoid delays. Here are Regulatory Joe’s Recommendations:

Audit Your MPMS and HIOS Access

Since only two users per organization can access MPMS, ensure that the right personnel hold these seats. The seats should be assigned to:

• A subject matter expert responsible for building and validating Plan and Benefit Templates
• A leadership-level contact who liaises with CMS, state regulators and reviewers

Align Your Plan Portfolio Early

Before submitting data to CMS, finalize your 2026 portfolio strategy, including:

• Plan structure and tiers (platinum, gold, silver, bronze)
• Cost-sharing details (copays, deductibles, out-of-pocket limits)
• State-specific benefit requirements that may not align with CMS’s federal validation tools

Run Compliance Checks Early

Once your portfolio is set, transfer your data into CMS templates one plan at a time. Be sure to run validation tools after each entry instead of waiting until all plans are inputted. Early validation helps issuers spot compliance risks before submission—reducing the need for justifications later.

Implement Version Control for Justification Forms

Given that Justification Forms will now be generated after submission, issuers must track each version of their Plan and Benefit Templates (PBTs) carefully:

• Version 0: Initial internal version before submission
• Version 1: Version officially submitted to CMS
• Version 2: Updated version following CMS-generated justification
• Version 3+: Further iterations based on CMS/state reviewer feedback

Maintaining version control across all CMS templates (PBT, pharmacy, rates, network, service area) ensures better organization and faster resolution of compliance issues. Tools like ClearFile’s automated compliance tracking can simplify version management and reduce errors.

Anticipate Justification Trends

Look at previous years’ objections and CMS feedback to predict potential future changes. Reviewing regulatory insights for health plans can help issuers stay ahead of shifting requirements.

Plans should consider:

• Where past justifications were required
• Common compliance triggers in CMS validation tools
• State-specific requirements that may involve additional documentation

Developing a matrix of common changes and their root causes can streamline future justifications and prevent unnecessary compliance issues.

Final Thoughts on the MPMS Plan and Benefits Process

The move to MPMS-based Plan and Benefit Justification Forms isn’t just a minor process update—it’s a fundamental shift in how issuers will manage compliance and approvals. With justification forms now controlled by CMS and issued post-submission, waiting to react is no longer an option.

Health plans need to take a proactive approach to ensure the right team members have MPMS access, strengthen internal validation processes before submission and implement version control to track changes and justifications.

With CMS continuing to shift regulatory processes into MPMS, this is likely just the beginning. The best way to avoid delays is to adapt now—because waiting until submission could leave issuers scrambling to justify their plans.

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, and today we’ll be talking about MPMS and the Plan and Benefit Justification process.   

So let’s just dive right into it. What is MPMS and what is the Plan and Benefit Justification process?

Well, for those of you who are close to the work and have worked directly with health plan filings for more than one year, you would have been around at the time when CMS transitioned the submission process in HIOS to MPMS.

Now, for the past number of years, CMS has always published their templates, tools and instructions on an annual basis in draft and final format on the CMS application web page.

Up until this past plan year, when CMS releases their draft and final templates, they always release the Plan and Benefit Template in tandem with the Plan and Benefit Template Justification Form, which is usually a PDF document with fillable fields [00:01:00] alongside the Excel file that they publish.

The really important takeaway for 2026 is that CMS has migrated the PDF justification form from the application web page into the MPMS portal.

The really big reason of why this is so critical for issuers and users is because the MPMS portal, for those of you who actually have access and utilize the system, in the PM community, generally only allows two users to have access and seats in the system.

So step number one is we really want to recommend that issuers across the country, whether you’re a big organization or small organization, really reconciles your access to MPMS and your access to HIOS. Are your current users in the system accurate and your current staff on hand assigned to the work to complete this for 2026, responsible for developing your plans and benefits, creating the template, validating the template, and submitting it to CMS. We want to make sure that that subject matter expert has direct access to MPMS and even possibly the PM community.

We want to also make sure that somebody on a leadership level or a middle management [00:02:00] level who has connections with your CMS account manager, your state regulator, or your reviewer to also have access to MPMS, as well as the PM community, taking up those two seats for your organization.

Now, while we don’t exactly know why CMS has limited the users to only two per organization, it’s really important that you have two people who are reliable for this plan year that can actually go in and receive routine updates on your Plan and Benefit Template, communications from CMS and automated emails as they go through the review process. Because unlike in past years, that justification form is no longer controllable by your issuer.

So, how does it actually work and when does the process actually start? You’re probably working on your plan portfolio design, tinkering around with cost shares and copays with your benefit administration team or your actuarial team.

At the point in time where you finalize your 2026 portfolio design and strategy, including your number of plans, including variants, number of plans by metallic tiers, whether that’s platinum, bronze, gold, silver, or expanded bronze, [00:03:00] and any programs that you want to wrap around your plan, we recommend that you create something similar to a benefit grid or an Excel spreadsheet to describe the benefits by plans that you have that you would like to offer for this plan year.

Once you come to final alignment with your leadership and internal team on your final portfolio strategy for plan year 2026, we recommend then you download the templates, whether they’re draft or final, from the CMS application webpage and begin to migrate that data from your plan portfolio sheet to the federal template.

As a best practice, we recommend that you convert data from your internal source of truth to your federal template, one plan at a time. Whatever priority order you’d like, we recommend you build in one plan on your benefits package tab, followed by your cost share variant tab, and run validation checks, each and every plan.

Now the value add to actually running your validation tools, each plan, instead of waiting until you’ve populated your entire portfolio suite, is to mitigate issues that would otherwise be found on your Plan and Benefit Template justification form. [00:04:00] The tools put forth by CMS that you’re running on the Plan and Benefit Template inherently have methodology from CMS that will call out if your plan is in compliance or out of compliance. Generally speaking, we can bring this full circle. That’s why justification forms are required in the first place.

Even as issuers are running the federal tools, on any template for that matter, issuers are provided the opportunity to justify any type of tool result that puts them out of compliance. Now you may be asking yourself, well how is it possible that if CMS deems a plan as non-compliant, how could an issuer possibly be able to justify that it’s an actually compliant plan?

Well, it’s interesting because the CMS tools and federal templates generally follow CMS programmatic rules and requirements only. CMS’s tools do not incorporate state-based requirements or state-based specifics. So for example, any state on a federal exchange, generally speaking, if you have an ACA compliant plan on the FFM, is going to pass a tool with no justification required.

 Generally speaking, issuers will have more opportunity [00:05:00] to justify a plan that CMS feels is out of compliance to actually make that plan compliant. While most of you or some of you may be familiar with that process today, why is it important that we’re calling it out for 2026? Well, in years past, that justification form was provided to issuers up front, where issuers would have the ability to provide a justification form at the time of submission to CMS, at the time of submission to a state division of insurance, around that May 15th, June 15th time frame.

 The problem that it actually creates for issuers is that justification forms are now produced by CMS post submission. So issuers actually have to essentially throw a dart at a board to understand if their plans are actually compliant or non-compliant and wait for CMS to review the application in order to produce a justification form.

So tying it back full circle, this is why it’s so critically important that you have the right people for the right reasons with access in your MPMS system. The right folks are the subject matter experts in your PM community to be able to actually [00:06:00] collect that justification form and get notified as the regulators and reviewers are reviewing your plan and approving or denying your application.

While streamlining operations, and as we do see CMS moving more functions up into MPMS, can overall be a good thing for operations and for documentation of business process, we do see that some of the big challenges that this is going to cause issuers is surrounding timing, cross-functional dependencies, and even the biggest impact could be hindering approvals for your plans. But I want to dive in just a little bit in terms of one of the impacts when you actually do receive a Plan and Benefit Justification form, generally it will come by way of automated email from CMS to the folks that have the seats in your PM community.

 We know the Plan and Benefit Template is really a core driver of up to over a dozen documents across any filing and submission. When we work with different organizations, you can see that some companies treat one benefit justification form as one change. But we view it very differently than that. If you’ve ever worked in a PBT before, you know that if you change one component, [00:07:00] one cell on either tab of that Excel file, it truly, truly inherently impacts almost everything else about your filing.

Even changing the smallest cost share or copay, whether it’s a PCP or specialist visit or a PTOTST, even a drug copay on your formulary, all of that’s going to cascade down through a justification form and could impact up to 10 to 12 or even more documents across your portfolio.

So really to mitigate the risk for this upcoming year, we want you to take a hard look at how your plan performed last year. Where were your objections? Where did you receive your request for changes in your PBT? What actually changed and why? Based on those changes, you can have a level of benchmark data of what could be asked to be changed for plan year 2026.

We also encourage issuers and anybody working in the PBTs to develop a matrix of common changes. Anytime a Plan and Benefit Template is touched, you almost always, always have to augment a form filing. So again, understanding common themes for your changes and putting them in buckets, we call that root cause analytics. So [00:08:00] understanding where the root causes of your changes are coming from will be critically important for getting ahead of the new justification process.

We recommend also developing a versioning control process if you don’t have one in place today.

Each time you create your initial Plan and Benefit Template, we consider that version 0. When you submit a Plan and Benefit Template, we consider that version 1. Anytime a justification form will be produced and sent to you by CMS , or any state partner, we then consider that Plan and Benefit Template converting to version 2.

If you receive another justification form or request for update, we then want to make sure that PBT references version 3, so on and so forth.

And to really streamline your internal operations and core business process, I can’t stress enough the importance of versioning control with your templates. Now Plan and Benefit Template and the justification form is one thing, but you should really apply the principle of version control across all templates in the CMS template suite., so even PBT, pharmacy, rate, network, or service area, and also your [00:09:00] internal documents as well. You really want to be able to develop a core repository where you can look back at former documentation, year over year, and actually understand the changes that occurred quickly and concisely.

And one last thing I wanted to touch on, which is more important for executive sponsors and more of the leadership in organizations, a little bit further removed from the work, is the approval process. One of the big implications for 2026 that may impact issuers on a leadership level is delays in approvals. Having the justification process pre-approval allowed issuers to justify their plans and have quicker speed to market, allowing them to focus more on enrollment readiness functions.

Having the justification process now ingested post-approval may hinder approvals closer to the September, October timeframe ahead of enrollment. This could impact how you produce your advertising filings for use and approve or how you market your product, ultimately impacting your membership.

All in all, these are just components we encourage you to look out for in the longterm, and that this is also not going away. If [00:10:00] CMS is now pushing the Plan and Benefit Justification form into MPMS, we do see a theme that they will continue to put other justification forms for templates and supporting documents into MPMS as well.

 It’ll be very important for you and your team to proactively document changes you think may result in a justification form. It’ll save you time and speed to market, get you approvals more quickly, and help alleviate any review process or rework with your regulator and CMS.

At the end of the day, I think we can all agree justification forms are here for a reason and they’re here to stay. But that being said, it won’t hurt to get ahead of the process and changes for this year to save some time and to optimize how we go to market. That said, give us a like, give us a share, and we’ll see y’all next time.