With each new ACA plan year comes a familiar challenge: ensuring that every plan you submit is compliant, competitive, and operationally feasible. As plan year 2026 approaches, reconciliation and validation remain the twin pillars of that process. But with evolving CMS tools, shifting deadlines, and increased complexity, getting it right early is more important than ever.

What Is Reconciliation and Validation in ACA Plan Design?

In the context of plan development, reconciliation refers to the incorporation of all required federal and state regulatory changes, as well as lessons learned from the prior year, into your product portfolio. Validation ensures that any strategic changes layered into your plan designs, like benefit adjustments or new product offerings, don’t inadvertently push your plans out of compliance.

Together, these processes act as both a safety net and a launchpad: helping issuers avoid penalties and rework while positioning plans for market success.

Balancing Required Changes with Strategic Plan Adjustments

It’s critical for issuers to implement non-negotiable CMS and state changes as a first step. This includes mandated updates to deductibles, maximum out-of-pocket limits, co-pays and other state-specific cost-sharing requirements.

These required updates should always be addressed first, as they directly affect your plans’ actuarial values (AVs) and compliance with metal tier standards. Once those baseline updates are in place, issuers can begin layering in strategy-driven changes—such as benefit design updates, premium pricing strategies, or competitive plan enhancements.

This sequence is more important than ever. In a surprise move, HHS released new AV calculator ranges for plan year 2026 after publishing the final AV calculator back in January. The revised ranges, now posted on the Federal Register, expand the allowable +/- tolerances and have left carriers needing to rework their metal plan designs between March 22 and April 15—just weeks before initial filings.

For issuers already juggling required and strategic changes, this adds a new layer of complexity. Making unplanned changes too early—or without visibility into late-breaking CMS updates—can trigger AV misalignments or compliance issues that are difficult to course-correct under tight submission timelines.

How to Navigate CMS Template Updates and MPMS Tool Migration

For plan year 2026, CMS is once again updating its template suite and validation tools, with many moving from desktop-based applications to the Marketplace Plan Management System (MPMS). At least seven updated templates are expected, including the Plan and Benefits Template, Business Rules Template and Rate Data Template.

These will come with new instructions and business rules, and while it’s tempting to wait for the “final” versions, history shows that draft templates rarely change. Issuers are encouraged to treat draft templates as final, begin populating them early and test plan designs using available validation functions.

Starting early not only mitigates risk but can save weeks of time as deadlines approach. It also provides a clearer picture of how strategic changes will impact compliance and operational execution.

Regulatory Joe Recommendations

To execute reconciliation and validation effectively, issuers need more than templates—they need structure, alignment, and foresight. Here’s how to get there:

• Centralize your data: Build a master product grid segmented by line of business and metallic tier. Whether it’s Excel, OneNote or a more robust system, make it your single source of truth for cost shares, co-pays and plan variant data.
• Establish cross-functional workgroups: Collaboration across product strategy, compliance, project management and downstream partners ensures that changes are tracked, communicated and implemented consistently, reducing rework and submission delays.
• Use version control: As plan documents evolve, meticulous version tracking is essential. This applies to everything from benefit configurations to template uploads.
• Consider member impact: Strategic changes like plan discontinuations or crosswalks have direct consequences for members. Always factor in cost-share shifts and tier migrations to minimize confusion and ensure regulatory alignment.
• Monitor CMS communications: Attend CMS webinars, track updates on template/tool changes and incorporate CMS feedback into your internal timelines.

Reconciliation and validation aren’t just boxes to check—they’re core to your organization’s ACA strategy. By prioritizing required changes, starting early with draft templates, and aligning your internal teams, you’ll position your plans for a smooth submission season and a successful launch in 2026.

Now is the time to get organized, get aligned and get ahead.

Subscribe for new videos sent right to your inbox!

---

VIDEO TRANSCRIPT

[00:00:00] Hey everybody, welcome to Regulatory Joe. I’m Joe Boyle, President of Regulatory Solutions here at Penstock, and on today’s episode we’ll be discussing reconciliation and validation for plan year So, what is reconciliation and validation?

So, in the short of it, reconciliation is making sure all the lessons learned that you completed and collected from the prior year are incorporated into your plan portfolio for the future year, as well as the absolute required changes from CMS and the states that participate in.  

Validation, on the other hand, is making sure that you’re incorporating the unplanned and strategy changes into your portfolio following the required changes, making sure that you still meet all the required ranges, actuarial values, metallic tiers, and compliant rules.

It’s a really [00:01:00] even balance, similar to a seesaw, to making sure that once you are compliant that you can also be competitive in the marketplace without being subject to penalties or other circumstances.

There’s really two fundamental layers and components of how you should be approaching this process.

First and foremost, it’s making sure that you’re incorporating all required federal and state changes that are non-negotiable into your plan portfolios for the new plan year. The second tier of reconciliation is making sure all your unplanned or customized strategy changes are also incorporated in that second layer below the federally required changes and the state required changes. 

We recommend that you tackle the required changes first to making sure such things like the required deductible limits, maximum out-of-pocket limits, and other such PCP co-pays or specialist co-pays dictated by the states you participate in are codified in your form documents, in the databases that your organization uses, whether it’s a Cognos database, a data warehouse, or a custom build report, [00:02:00] or even something as simple as a Excel spreadsheet for those organizations that may be smaller and not have those large data capabilities to house your cost shares and co-pays.

It’s really important to make sure you make those required changes first, because you need to make sure your issuers are filing compliant plans in the Federal Marketplace. 

It’s also very important to make sure that the required changes are done first, because as you make your unplanned strategy changes to your portfolio, that’s going to move your actuarial value and the actual metallic limits of your plan. Making sure your plans are compliant is going to be very important, because it’s going to be a race against the clock as you get closer to submission deadlines, both internal and external.

The other key part about reconciliation and validation, it’s really important to understand the changes that you’re making and the versioning control of those changes.

Generally speaking, when we talk about the ideation and timeline of developing your product strategy, it’s really important to know that that takes time. It should take a number of weeks for a product strategy team to make sure you can codify those benefits, price your [00:03:00] strategy to an appropriate premium price, and your go to market strategy.

We encourage you to wrap a timeline around to set key dates between now and your submission due dates externally to CMS and the state you participate in to make sure you don’t miss any deadlines.

It’s really important to have a structure in place once you’ve harnessed reconciliation and validation within your organization to making sure you establish the right work groups, your implementation with stakeholders across all your functional business areas, to make sure that when you make those required federal changes and state changes and those customized strategic changes that everybody else in your downstream partners are aware, they’re informed of the changes, they’re ready to accept the changes and making sure that they’re coding them, whether it’s in their downstream documents, materials, their own templates that are required for plan filings, internally or externally. The last thing you want is a situation where changes are not communicated effectively and that it would result in rework, objections, [00:04:00] downtime, or even worse, a penalty or a fine or a member complaint.

Making sure that these changes are collected and captured up front will only streamline your business process and help your team focus on more strategic initiatives.

So what exactly is changing in plan year 2026? Well, it’s important to know that while CMS has not finalized and released everything that they intend to, to date right now, we already can anticipate that CMS is changing the templates, the tools and the instructions like they do every single plan year.

To get a head start on these new materials, we encourage issuers to start playing in the sandbox environment of MPMS, starting to tinker around with templates from last year in anticipation of CMS releasing new 2026 templates for the future plan year.

So while some of you may be thinking that it’s too early to start this work and testing your plan designs in MPMS and running the validation tools, it’s always important to remember with the draft templates being released, generally speaking, the first week of April on each year, the final templates are almost always released by [00:05:00] the second or third week of April annually.

So while we understand that an urge to wait for those final templates to be released, historically, please remember, CMS has almost never changed the templates between draft and final. Always try to treat your draft templates as final templates. It will ultimately save you weeks and dozens of hours of your time if you start to populate those drafts, run the tools with the validation functions that are proposed to be final, and augment and just make these small, tiny changes, if needed, at that final release date.

We know at minimum, CMS will be releasing up to 7 new templates, the business rules template, the rate data template, even the most complicated, the plan of benefit template. 

All those core templates will also be supplemented with new sets of instructions and business rules alongside them.

Really where the tricky part comes into play, which we’re encouraging issuers to really hone in and track and follow is the tools. Now, it’s really tricky because CMS, as you all know, folks close to the work last year are starting to migrate the desktop tools that were previously [00:06:00] published into MPMS.

With the webinars from CMS starting to be released, we encourage you all to attend those to understand the changes, collect updates, and understand which of the desktop application tools that you’re most familiar with will then be migrated from the desktop up into MPMS for plan year 2026. While the functionality may be a little bit easier, it’s actually hard or even impossible to tell at this point if they’ve changed the way error reconciliation will be produced, the actual error reconciliation numbers to tie back to instructions to understand the root cause of what the issue is and how to fix it.

And to bring it full circle, it’s really interesting because when we put this on a timeline, CMS releases these items on an annual basis based on the feedback, the performance, and the quality of what issuers provide the year before.

So full circle. When the draft Notice of Benefit and Payment Parameters is released and issuers are given the comment period to provide feedback on what worked well for them and where there’s opportunity for improvement, you should also [00:07:00] be incorporating comments in a position on your issuer and your performance of the templates, the tools, the instructions, the validation components, and even such things like the methodology of how CMS is creating these tools and what the results and reconciliation efforts mean for your company.

So a few strategies we recommend as you enter busy season are first and foremost, be organized. And when I say that, regardless if you have your plan designs working on an Excel spreadsheet, a Word document, or even a OneNote, recommend breaking that up into easily digestible and understandable tabs.

Something as simple as a tab for your small group business, your individual business, and actually breaking it down in subsets based on metallic tier. Gold, silver, bronze, expanded bronze, even platinum. It’s going to be important because as you work with your work group and your implementation team and your project manager and your product team, you need to make sure that as decisions are being made by your plan, by plan ID, or even plan variant ID, that you’re incorporating those into your benefit grid.

This could be [00:08:00] referred to as something as a product grid, a benefit grid, or even something like a marketing grid as you go downstream to your broker and sales partners. What you really want to do is make sure this becomes your source of truth. Ultimately, what’s going to happen over time is as you make your decisions, whether it’s your first plan year entering a new market, or if this is your second, third, or fourth plan year, renewing yourselves in an existing market, is this will become your single one-stop shop document that you’ll rinse and repeat year over year.

So that being said, whether you’re adding plans, discontinuing plans, or crosswalking plans because they don’t meet certain AV values or Certain components dictated by the state you’re participating in are by CMS, that’s why it’s so important that you’re running the tools constantly, whether it’s on your desktop or within CMS on MPMS on the web, to make sure that the plan decisions you’re making are actually going to make it into your portfolio so a member can enroll and click and pay their premium for the plan.

It’s really interesting because the ideation of product development is you can have [00:09:00] ideas and make changes that are strategic for your company and for your organization, but not necessarily feasible financially for your plan or operationally to actually execute. So what we’ve learned over the past number of plan years is that certain plan decisions actually may result in substantial plan changes.

We’ve seen carriers add new plans to be more competitive where their previous plans are falling out of range or falling out of compliance. What does that mean for that member? If you are discontinuing plans, always make sure that cost shares and co-pays have a member impact. Members should always be at the forefront of the plan decisions you’re making, especially if it involves plan crosswalking them into different metal levels or metallic tiers.

So I’ll just reinforce one more point because everything we just discussed is much easier said than done. Over the course of April, May, and June, just make sure that you keep consistent and persistent with your implementation work groups, your versioning control, and the collaboration between your project manager, your product team, and your internal stakeholders. That said, thanks everybody for [00:10:00] listening in.

Give us a like, give us a share, and we’ll see y’all next time.