HHS is proposing to codify guidance in the document titled, ‘‘Reporting and Reviewing Data Inaccuracy Reports in State-based Exchanges Frequently Asked Questions’’. [34] Currently, State Exchange issuers work with the State Exchange and issuers to address any data accuracies used to calculate APTC payments, although information provided to HHS is considered informational and HHS cannot directly assist the State Exchange issuer in addressing these data inaccuracies. Essentially HHS proposed when a State Exchange received adequate information (per § 156.1210(a)–(c)_ regarding a discrepancy in data, they would have 60 days to make a correction. This was finalized as proposed, and HHS notes this is different than the 90 day calendar window for State Exchange issuers to report inconsistencies.
Not all enrollees submit coverage applications themselves. Application filers are currently permitted to file applications on behalf of an applicant. However, if eligibility is contested, the applicant themselves would need to contest the eligibility determination. A proposal was made to permit an application filer to appeal a contested eligibility determination on behalf of an applicant and enrollee. [35] Applies to HHS exchange entity or State exchange entity. HHS will not require additional appeal consent language, and believe the current language allowing filers to file applications on behalf of an applicant is sufficient. This was finalized as proposed.
While not a change to the authority, HHS proposed to make more explicit the Exchange’s authority to deny a QHP certification if it does not meet general certification criteria.[36] HHS is not proposing to require Exchanges, including State Exchanges and SBE–FPs, to implement any specific procedures or processes for the denial of a QHP certification application. The language was finalized as proposed.
An issuer interested in offering qualified health plans (QHPs) to be offered on an exchange, an annual application process is in place to ensure the plans meet all requirements. If there is a denial of a QHP in an FFE that an issuer asks to be reconsidered, a proposal indicates the burden of proof in on an issuer to provide clear and convincing evidence that HHS’ determination was in error.[37] New data would not be considered clear and convincing evidence. This was finalized as proposed.
Basic Health Plan – Premium Adjustment Factor (PAF) Change
Under the ACA, a Basic Health Plan (BHP) can be established by states to offer health coverage to low-income individuals otherwise eligible to purchase coverage through Health Insurance Exchanges.[38] The payment amount made to states that establish a BHP (Federal BHP payment) must equal 95% of the value of the sum of the premium tax credit (PTC) and cost sharing reduction (CSR) payments that would have been paid on behalf of BHP enrollees had they enrolled in a QHP through an Exchange, where the CSR portion is currently zero as HHS is not making CSR payments.[39] The 2026 Payment Notice provides a summary of the methodology used to determine the BHP payments, which was explicitly discussed in detail in the 2023 Payment Notice.
[34] C. Part 155—Exchange Establishment Standards and Other Related Standards – 4. Timeliness Standard for State Exchanges To Review and Resolve Enrollment Data Inaccuracies §155.400(d)(1)
[35] C. Part 155—Exchange Establishment Standards and Other Related Standards – 6. General Eligibility Appeals Requirements (§155.505)
[36] C. Part 155—Exchange Establishment Standards and Other Related Standards – 7. Certification Standards for QHPs (§155.1000)
[37] C. Part 155—Exchange Establishment Standards and Other Related Standards – 8. Request for the Reconsideration of Denial of Certification Specific to the FFEs (§155.1090)
[38] https://www.urban.org/research/publication/implementing-basic-health-program
[39] A. 42 CFR Part 600 BH