Final Rule for 2026 Healthcare

 

Behind the scenes rulemaking takes place every year to improve the Affordable Care Act. It is done by the US Department of Health and Human Services alongside the Centers for Medicare and Medicaid Services. It is usually reserved for us policy nerds. This year was different.

A large Coalition of Attorney Generals have sent a letter to Dr. Mehment Oz to withdraw most of the proposals because of their detrimental effect. 

If just one or two of these proposals go through it will mean massive changes with the Affordable Care Act Plans. 

This is in addition to the lose of the enhanced tax credits which will already raise prices and result in the massive loss of coverages. The average enrolling saved $705 in 2024 because of these enhancements which is the equivalent savings of 44%. 

These are not all the changes but some of the big ones.

1. The Final Rule has all exchanges ending Open Enrollment December 15th. In Washington State we have never had an enrollment period that short. With the overlap of the Medicare Annual Enrollment Period, it is going to make getting assistance understanding the changes harder. 
2. Ending the Special Enrollment Period for the 150% of Poverty Level and Below. This has been a major benefit for people that struggle with employment and coverage. By ending this Special Enrollment, we will see increased people mid year without coverage increasing costs to providers.
3. Moving the Special Enrollments' Documentation to the Exchanges. Currently, this task is with the Insurance Companies and will add complexity and documentation at a location that does not need to be there. (Page 7)
4. Allowing Health Plans to deny coverage for previous past due premiums. There will be consumers with no idea of money owed when plans are selected so it may lead the consumer into a problem that prevents them from gaining coverage for the year. In addition, it is not just the previous year, it is for years. (page 10)
5. Elimination of Deferred Action for Childhood Arrivals (DACA or Dreamers) participating on the exchanges. This was a harmful exclusion of mostly people under 20 that were locked out of being able to purchase health insurance. This is the students, business owners, and stay at home moms without a means to participate in their local healthcare system. (Page 17).
6. They are looking at changing the actuarial level from plus or minus 2 to plus or minus 5. This is going to tarnish the bronze, silver and gold metal rating system blurring out the distinction of the plan levels.  There are people that purchase based on metal levels and if this goes through and they purchase an under performing silver then it will be closer to a bronze plan which will create discouragement. (page 12)
7. Eliminating the "crosswalk" policy reduces plan value to consumers with no benefit. Under the current policy, an enrollee who selects a bronze tier plan, where a silver-tier plan is available at the same or lesser cost in the same network, will be automatically enrolled in the better plan.  (page 13).
8. Ending the acceptance of self-attestation of projected annual income for 100% of poverty level. This helped seasonal and part time secure healthcare. 
9. Broker-focused anti-fraud provisions. Are just naturally a bad idea as they reject the options suggested by professionals in favor for a position that the largest and worst offenders will profit from. We love the Healthplanfinder's three way call verification which reduces fraud and hope other states adopt this model. 
10. This is the one that I literal knew would be top out of the gate last November. The exclusion of Gender Affirming Care from the Essential Health Benefits. (page 39) There is literally Section 1557 of the original ACA on why Gender Affirming Care is important. This change violates the equality protection clause and classifies based on sex. 

Good job to the  Attorneys General of California, Massachusetts, New Jersey, Arizona, Colorado, Connecticut, the District of Columbia, Delaware, Hawai‘i, Illinois, Maine, Maryland, Michigan, Minnesota, Nevada, New Mexico, New York, Oregon, Rhode Island, Vermont, Washington, and Wisconsin for telling the administration that their actions will harm healthcare. 

While Medicare and Medicaid are getting a lot of talk, you should talk to your representatives because these changes will have dramatic effects this fall. 

If you have an agent then set your appointment early from November 1st to December 15th as it is going to be packed with people needing help.