Breaking Down the 2026 NBPP: Affordability, Access, and Expanded Roles for Navigators
December 19, 2024 | By Mary Hunt Moore, MPFM, and Sarabeth Zemel, JD
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On October 4, 2024, the Centers for Medicare & Medicaid Services (CMS) published its proposed Notice of Benefit and Payment Parameters (NBPP) rule for the 2026 plan year.
This rule is released in the late fall each year and includes proposed changes to the regulations that govern the operation of the Health Insurance Marketplaces, standards for health plans, agents and brokers, and Navigators. The proposed rule is expected to be finalized in January, before the change in presidential administration.
These changes could significantly shape how Navigators and enrollment assisters work, from streamlining appeals to expanding Navigators’ role in helping consumers apply for medical debt assistance.
Here are the proposed NBPP updates all assisters need to know about:
Simplifying Appeals Processes for Consumers and their Families
To minimize administrative barriers that consumers and their families face when filing Marketplace appeals, CMS is proposing to allow any family member to file an appeal on behalf of an enrollee in their household without requiring them to become an authorized representative first, as is currently the case. This would facilitate Navigators’ efforts to help consumers file appeals on behalf of family members.
Strengthening Network Adequacy Standards
The proposed rule includes time and distance standards as well as appointment wait time limits, aiming to ensure better access to timely care. The recommended standards align with similar standards included in the Medicaid and Children’s Health Insurance Program (CHIP) Managed Care Access, Finance and Quality rule issued by CMS earlier this year.
Expanding Navigator Responsibilities
Citing medical debt as a major barrier to financial stability, even for those with health insurance, CMS is proposing the expansion of Navigator responsibilities to include assisting consumers with applying for medical debt assistance programs offered by nonprofit hospital systems. If finalized, Navigator programs and hospital systems may need additional training and support to ensure successful collaboration. The American Hospital Association commented in support of this proposal in a letter to CMS.
Risk Adjustment Updates
Risk adjustment among Marketplace issuers is meant to support plans that cover high-cost enrollees and stabilize premiums. In the 2026 NBPP, CMS proposes two key changes in risk adjustment:
- Affiliated Cost Factor (ACF): This will adjust for costs unrelated to current medical conditions, such as Pre-Exposure Prophylaxis or PrEP and gene therapies.
- Medical Loss Ratio (MLR) Adjustment: For qualifying issuers that receive large amounts of risk adjustment payments, CMS proposes moving these payments to the MLR denominator to better reflect insurers’ financial realities.
Impacts to Affordability
Several updates, including changes proposed in the actual 2026 NBPP rule and separately issued CMS guidance, could increase costs for both issuers and consumers. These changes affect premium prices, out-of-pocket maximums, and Marketplace user fees, which could all impact affordability.
Higher Out-of-Pocket Maximums
Each year, the out-of-pocket maximums (OOPMs) for qualified health plans (QHPs) are adjusted based on the premium adjustment percentage (PAP) methodology that is outlined in the ACA. This methodology ties OOPMs to national health expenditure trends.
For 2026, no changes to the PAP methodology were proposed in the NBPP and CMS subsequently issued the PAP and OOPMs for 2026 in separate guidance on October 8, 2024. For 2026, the increase is significant and reflects rising healthcare expenditures.
- Individual: $10,150 (up 10.3% from the current OOPM of $9,200 for an individual in 2025)
- Family: $20,300 (up 10.3% from the current OOPM of $18,400 for a family in 2025)
These changes could increase the financial burden for individuals and families with high medical needs who are more likely to reach their OOPM.
Silver Loading
Silver loading is a practice that issuers have adopted following the end of cost-sharing reduction (CSR) reimbursements in 2017, in which issuers increase the premiums on silver-level plans to account for the costs of providing CSRs to eligible enrollees. This increase in premiums is not passed on to the CSR consumers, however, because their premium tax credit (PTC) amount will also rise proportionately. Because PTC amounts are determined based on the cost of the second-lowest cost silver plan, this practice generally increases federal spending on PTCs overall.
The 2026 NBPP clarifies that silver loading is permissible under federal law, so long as it is reasonable and actuarially justified. Further, CMS is considering codifying this policy in the final rule to provide additional clarity and consistency.
Broad loading, the alternative approach to silver loading, is a pricing strategy in which costs associated with CSRs are recouped by raising premiums across all metal levels. While broad loading is not part of the proposed rule, this context is useful for understanding how different pricing strategies could impact consumers and federal spending. Because the cost of unpaid CSRs is spread across all plans, broad loading does not have the same impact on PTC amounts as silver loading and therefore does not have the same effect on federal spending, but it would impact affordability, particularly for consumers ineligible for premium tax credits.
Marketplace User Fee Increases
User fees to support Marketplace operations, such as technology upgrades and outreach efforts including Navigator programs, are charged to issuers offering their plans on the Marketplaces. Citing uncertainty in the ACA markets due to the potential expiration of enhanced PTCs after 2025, CMS includes two potential user fee rates for 2026.
Assuming enhanced PTCs expire at the end of 2025, CMS proposes:
- FFM User Fee: 2.5% of monthly premium payments (up from 1.5% in 2025)
- State-Based Marketplace on a Federal Platform (SBM-FP) User Fee: 0% of premiums (up from 1.2% in 2025)
However, if Congress extends the enhanced PTCs by March 31, 2025, CMS would lower the proposed 2026 rates. The proposed rule included a range but will be set at a single rate in the final rule.
- FFMs: 1.8%-2.2%
- SBM-FPs: 1.4%-1.8%
These increases are not significant compared with historical rates, but any increase in fees to issuers could be passed along to the consumer in premium increases.
Flexibility in Premium Payment Thresholds
Under current rules, issuers can terminate a consumer’s coverage if the amount the consumer pays is less than the premium amount owed. In the 2026 NBPP, CMS is proposing to change this by requiring issuers to establish a premium payment threshold, under which coverage cannot be terminated. The threshold could be a percentage or a flat dollar amount. For example, if a plan establishes a premium payment threshold of $5, a consumer who accidentally underpays by an amount of $5 or less would be protected from losing their health insurance coverage. This would be of particular benefit to consumers with lower incomes and lower premiums. The aim of this policy is to reduce administrative disenrollment and promote continuity of coverage.
Standardized Plans and Simplifying Consumer Choice
In the proposed rule, CMS maintains the requirement that QHPs on the FFM and SBMs include standardized plans in their offerings and reinstates rules requiring meaningful differences for non-standardized plans. While insurers can still offer non-standardized plans, reinstating meaningful difference standards will reduce the risk of plan choice overload.
Comments on the proposed rule were due on November 12, 2024, and you can view the public comments here. We’ll continue to keep you updated as more information becomes available, including when the final rule is published, likely before the administration changes.
Transform Health is a nationally certified women and minority led health care consulting firm. Reach out to us today if you would like to work together. Contact Heather Bates, COO, and VP of Stakeholder Engagement at heather@transformhc.com. We would love to hear from you!