Weekly Roundup -
May 27, 2026
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Connecting the Dots: Key Trends, Plan Shifts, and 2027 NBPP Changes Affecting ACA Marketplace Enrollment
Explore how 2026 ACA Marketplace enrollment shifts, plan selection trends, and the 2027 NBPP changes are impacting affordability, market stability, and state strategies.
Recent Health Management Associates (HMA) webinars and reports discussed that Affordable Care Act (ACA) Marketplace enrollment trends are evolving rapidly and the takeaways go beyond total enrollment numbers. In addition in May, the Centers for Medicare and Medicaid Services (CMS) finalized the 2027 Notice of Benefit and Payment Parameters (NBPP), introducing new flexibility for plans and states alongside stronger program integrity requirements.
To understand how these changes are reshaping the ACA Marketplace, Andrea Maresca spoke with Zach Sherman, Managing Director for Coverage Policy and Program Design at HMA as well as Michael Cohen, PhD, Principal at Wakely, and Liz Wroe, Principal at Leavitt Partners, both HMA companies.
Q: The recent Wakely analysis has been central to understanding what’s happening with ACA enrollment. What should people be paying closest attention to?
Michael Cohen: The key takeaway is that ACA Marketplace trends are about much more than the enrollment numbers. The plans consumers choose, how long they maintain coverage over the course of 2026, and the evolving picture of the morbidity and demographics of the enrolled population are all critical factors for understanding the ACA Marketplace.
Our recent Wakely analysis found that only about 86 percent of enrollees paid their first premium in 2026. That’s a strong indicator that affordability pressures are already affecting coverage stability.
Q: Where are these enrollment changes showing up most clearly?
Michael Cohen: One data point that stood out is the number of new consumers in 2026, which was down 13 percent compared with prior years.
The impact also shows up in coverage losses and consumer plan selection. Some consumers are dropping coverage altogether, while others are making tradeoffs to stay covered. These consumers are moving to lower-premium products—particularly from silver to bronze plans—which offer less robust coverage and higher out-of-pocket costs. Both trends matter, especially when thinking about access and financial risk.
Q: How are enrollment shifts affecting broader ACA Marketplace stability?
Zach Sherman: It varies by state, but there are notable trends. States that are using the Federally Facilitated Exchange (FFE) and expanded Medicaid saw the largest enrollment declines.
Notably, non-expansion states on the FFE significantly outperformed expansion states. This was surprising because, with enhanced subsidies ending, the biggest net premium hit consumers would feel is at the lowest income levels, yet that’s where we saw most enrollment growth.
Across the individual states, the enrollment shifts have real implications for stability. When healthier individuals leave the market—or shift to less comprehensive coverage—it can put pressure on premiums and risk pools. Issuers are taking this information to begin to make estimates for their 2027 pricing and what this means for their 2026 performance.
At the same time, CMS is introducing new flexibilities in the final 2027 Notice of Benefit and Payment Parameters.
Q: What are the most important changes in the 2027 final rule?
Zach Sherman: Broadly, the rule makes a clear push toward increased flexibility for consumers, plans, and state regulators.
One of the categories of changes is around expanded availability of lower premium plans with higher out-of-pocket costs. For example, catastrophic plans can now be offered for up to 10 years.
CMS also removed certain requirements for standardized plans and relaxed limits on non-standard plan offerings. That gives issuers more room for plan design innovation, but it also means a more complex landscape and plan selection experience for consumers.
One of the most notable changes is the introduction of non-network plans as qualified health plans. These plans don’t rely on traditional provider networks, which could lower costs while introducing new considerations for access and consumer experience.
We’re seeing a shift toward allowing more tailored options and potentially less standardized marketplace programs. It will require a different approach from regulators, and it creates a different type of experience for consumers.
Q: CMS is intensely focused on addressing fraud, waste and abuse. How is that playing out in the Marketplace program?
Zach Sherman: Program integrity is a central theme in the 2027 final rule, too. It includes stronger eligibility verification, increased oversight of brokers and marketing practices, and new safeguards to reduce improper enrollments. So while there’s more flexibility in plan design, CMS is pairing it with more scrutiny on how the system operates.
Q: Where do states fit in all of this?
Zach Sherman: The final rule gives states more authority in key areas, including oversight of plan network adequacy and essential community provider compliance. We’re deep into discussions with states and health plan issuers about the changes they’re interested in exploring for their state. States will have to decide how to use that flexibility to balance affordability, access, and stability.
Although many of the provisions take effect in the 2027 plan year, regulators and plans are receiving this information fairly late in the cycle which will make it difficult to incorporate some of the flexibilities. We’re anticipating robust discussions to continue next year and expect to see more variation starting in plan year 2028.
Differences and Alignment in Federal ACA Marketplace Policy Discussions
Q: Stepping back from the 2027 NBPP, what should interest-holders know about the evolution of the broader policy landscape?
Liz Wroe: Members of Congress will need to see the 2027 rates being filed before they consider taking action. Even then, there’s no consensus on several key issues that prevented a bipartisan deal to bring back enhanced subsidies in 2025.
Instead everyone has transitioned to a larger affordability conversation, and we’ll spend this year working on the policies with a goal of moving forward in 2027.
There are different approaches to affordability and coverage that are driven by fundamentally different philosophies on how to structure the market. Some proposals focus on expanding subsidies, reducing cost sharing, and strengthening ACA protections. Others emphasize consumer-directed models like defined contributions, health savings accounts, and expanded use of ICHRAs [Individual Coverage Health Reimbursement Accounts] as well as broader access to lower premium plans.
There are also several areas of bipartisan alignment. Prior authorization reform is a big one. There’s broad agreement that the current system creates administrative burden and delays in care.
We’re also seeing common interest in policy approaches to strengthen medical loss ratio [MLR] requirements, expand price transparency, and address provider consolidation.
Even if there is divided government after the November elections, these are areas where policy action may be more likely. States, health plans, providers, and other interest holders will want to monitor these issues now for signals of what may move forward later this year or in the next Congress.
Stakeholder Opportunities to Inform Marketplace Programs
Q: What should stakeholders be focused on right now?
Michael Cohen: For issuers, it’s about understanding how these changes affect pricing, enrollment, and risk. There’s more uncertainty in how plans should be priced.
Zach Sherman: For states, the focus should be on strategy. The choices they make now on plan oversight, market structure, and consumer protections will shape outcomes for several years. Additionally, there were several proposed Marketplace policies that CMS did not finalize in the 2027 rule—State-Based Exchange Enhanced Direct Enrollment Model—that CMS is likely to revisit in future rules, including the 2028 NBPP.
Liz Wroe: Broadly, stakeholders should recognize that we’re in a transition period. The market is evolving, and policy is still catching up.
Connecting the Dots: Enrollment, Rules, Regulators, and the ACA Marketplace
For stakeholders across the healthcare landscape, navigating this environment requires both technical expertise and strategic insight.
HMA works across policy, actuarial, and operational domains to help states, health plans, and other stakeholders translate these developments into actionable strategies—whether that means evaluating market risk, designing programs, or preparing for future policy scenarios.
To explore these issues in more detail, access HMA’s webinar discussions and briefs, including:
Federal Policy News
Fueled By Leavitt Partners Weekly Health Intelligence
New CMS Medicaid Rule Signals Tighter Payment Controls and Expanded Oversight
On May 20, CMS released the “Medicaid Managed Care State Directed Payments and Medicaid Fee-for-Service Targeted Medicaid Practitioner Payments” Proposed Rule. The proposed rule is intended to implement Section 71116 of the FY 2025 budget reconciliation law (Public Law 119-21), which directed CMS to revise the payment limit for certain state directed payments (SDPs) to providers within their Medicaid programs. The regulation also proposes new limitations on payments for services not addressed by the reconciliation law, in addition to establishing various new reporting requirements related to CMS’s program integrity focus.
The proposed rule would reduce the payment rate limit for certain SDPs for inpatient hospital services, outpatient hospital services, nursing facility services, and qualified practitioner services at an academic medical center to 100 percent of the total published Medicare payment rate for expansion states, or 110 percent of the total published Medicare payment rate for non-expansion states beginning for rating periods on or after July 4, 2025.
While the scope of the statutorily required changes impact four service areas, CMS has proposed to “extend the payment rate limit under the law to all SDPs for all services in all states, the District of Columbia, and territories for rating periods beginning on or after January 1, 2029,” with limited exceptions for certain services. CMS had signaled its potential intent to expand the scope of services captured by the law in guidance released February of this year.
Section 71116 allowed for certain SDPs to be grandfathered such that they would be reduced by 10 percent annually, until the allowable Medicare-related payment limit is reached, beginning January 1, 2028. The February guidance details the criteria for certain SDPs to be considered grandfathered.
The rule is open for public comment until July 21, 2026.
The release of the rule comes as CMS also prepares for the implementation of another major provision of the FY 2025 budget reconciliation law, community engagement requirements in the Medicaid program. June 1, 2026, marks the statutory deadline by which CMS must release an interim final rule, which is currently under review at OMB. This rule will significantly impact how much flexibility states have in implementing the requirements, including providing key definitions that will impact exemptions from the requirements and guidance regarding procedures for states to conduct enrollment determinations. As an interim final rule, the rule will be “final” or legally binding but will allow for public comment at the time the rule is promulgated.
FDA Moves Forward With Advisory Review of Moderna’s mRNA-Based Flu Shot
On May 21, FDA announced the Vaccines and Related Biological Products Advisory Committee (VRBPAC) will meet on June 18 to “discuss and make recommendations on the safety and effectiveness” of Moderna’s mRNA influenza vaccine.
Earlier this year, FDA’s Vinay Prasad, CBER director at the time, declined to accept Moderna’s application for review, issuing a refuse-to-file letter. However, a week later, FDA reversed its decision and accepted the Moderna application for review. Prasad left the agency in late April.
A docket for the VRBPAC meeting is open for public comment until June 17, and all comments received on or before June 12 will be provided to the Committee for review. Additionally, an hour has been allotted for public oral presentations at the VRBPAC meeting on June 18, from 1–2 PM ET. Those interested in conducting presentations are encouraged to submit a brief statement and contact information listed in the VRBPAC meeting webpage by 12 pm ET on June 8, 2026.
HHS Releases National Guidance on Screen Time and Child Wellbeing
On May 20, the HHS Office of the Surgeon General released a warning titled, “Surgeon General’s Warning on the Harms of Screen Use: An Advisory and Toolkit on how to protect children and adolescents.” Though there is not currently a Senate-confirmed Surgeon General, the report was issued under the leadership of Dr. Stephanie Haridopolos, Principal Deputy Assistant Secretary for Health and the Director of National Health Communication for the Office of the Surgeon General, who has been named “interim Surgeon General.” Through Dr. Haridopolos’ appointment as interim surgeon general, the Administration can leverage the messaging tool of the Surgeon General’s office, despite not having a confirmed Surgeon General. A nomination hearing for Dr. Nicole Saphier, the current nominee for Surgeon General, has not been scheduled.
The advisory on screen use details emerging science related to the impacts of screen time on the health and wellbeing of children and adolescents, while the toolkit provides action items for children, their families, schools, and healthcare providers to support prevent potential harms and “shift cultural norms” around screentime. The toolkit also includes policy considerations for school districts to support the development of a school policy related to screen usage, while noting widespread variation across 41 states that have enacted laws related to cell phone use in schools.
HHS Restructures Civil Rights Office Under New Enforcement and Policy Framework
On May 19, the HHS announced a reorganization for the Office for Civil Rights (OCR) that created three subject-matter divisions: the Conscious and Religious Freedom Division (CFRD), the Civil Rights Division, and the Health Information Privacy, Data, and Cybersecurity Division. The CFRD was originally created in 2018 under the first Trump Administration to “protect the fundamental and unalienable rights of conscious and religious freedom.” In March 2023, then-President Biden combined the CFRD with the Civil Rights Division under a singular “Policy Division,” leaving OCR with general jurisdiction over the subject. HHS states the new organization will work to “advance the protection of conscience rights, address race-based discrimination in a color-blind manner, eradicate antisemitism and anti-Christian bias, and restore biological truth.” Breaches of unsecured PHI will remain under the Enforcement Division’s jurisdiction. HHS noted that the reorganization will not result in a reduction of OCR’s workforce. Further information regarding this reorganization will be published next month in a Federal Register notice.
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State Policy News
California Submits Section 1115 CalAIM Renewal Request Seeking Employment Services, HCBS for Medicare Adults
The Centers for Medicare & Medicaid Services announced on May 27, 2026, that California submitted a request to extend its California Advancing and Innovating Medi-Cal (CalAIM) Section 1115 demonstration for five years. Within the amendment, the state is seeking new authority to provide pre-employment and employment sustaining services for certain beneficiaries, as well as authority for the Bridge Care Pilot, which would provide home and community-based services to older adults on Medicare that have significant needs but incomes above Medicaid eligibility limits. It also seeks to continue multiple services, including reentry services, substance use disorder services, traditional healthcare practices, and more. The current demonstration is effective through December 31, 2026. Public comments are due June 26, 2026.
Maine Plans County-Based Approach for Medicaid Re-Entry Waiver
Healthcare Innovation reported on May 24, 2026, that Maine’s Medicaid program MaineCare is currently negotiating with the Centers for Medicare & Medicaid Services (CMS) on its 1115 Medicaid re-entry waiver and is developing a county-by-county implementation approach rather a statewide model. If approved, the waiver would allow Maine to cover certain services for people up to 90 days before release from jails and prisons, including case management, medications for substance use disorder, and at least 30 days of medication at release. Maine also plans to include physical and behavioral health consultations for youth and services tied to needs such as HIV and hepatitis C. Maine’s approach is being informed by visits to all 21 jails and prisons, listening sessions with residents, and input from sheriffs, providers, corrections officials, and community partners. Implementation is expected in late 2027 or early 2028.
Minnesota Seeks Input on Medical Frailty Definition for Medicaid Work Requirements
The Minnesota Department of Human Services released on May 21, 2026, a Request for Information seeking stakeholder feedback on how the state should define “medically frail” individuals for purposes of Medicaid work and community engagement requirement exemptions under Public Law 119-21. The proposed approach would use available claims data from the state’s Medicaid Management Information System, including specified International Classification of Diseases, Tenth Revision diagnosis codes, to identify Medicaid expansion adults who may qualify as medically frail without requiring additional enrollee documentation where possible. The department is requesting input on clinical criteria, data sources, equity and access considerations, operational consistency, and outreach ahead of the January 1, 2027, effective date. Responses are due June 1, 2026.
Missouri Releases RHTP Rural Health Hub Anchors RFA
The Missouri Department of Social Services released on May 15, 2026, a Request for Applications (RFA) for rural healthcare organizations to serve as Transformation of Rural Community Health Care Hub Anchors under the state’s Rural Health Transformation Program. Selected Hub Anchors will coordinate regional healthcare ecosystems across roughly three to five counties, bringing together hospitals, clinics, pharmacies, emergency medical services, community-based organizations, and other partners to improve care coordination, referral systems, and community-specific health needs. Applications are due June 18, 2026.
Rhode Island Issues Medicaid EVV Module RFP
The Rhode Island Executive Office of Health and Human Services (EOHHS) released on May 25, 2026, a request for proposals (RFP) seeking a qualified vendor to administer the RI Medicaid OASIS electronic visit verification (EVV) Module. The state plans to implement a single statewide EVV solution as it transitions from its legacy Medicaid Management Information System to a modular Medicaid Enterprise System (MES). The EVV vendor will help Rhode Island improve accountability, accuracy, care coordination, and transparency in home and community-based services. The contractor will be a point-of-care verification and must interface with other modules via the System Integrator and Operational Data Store. Proposals are due July 14, 2026.
Private Market News
Fueled By Wakely Consulting Group
ACA Deductibles Reach Record High as Membership Losses Slated to Continue
A fuller picture is emerging of how the expiration of enhanced subsidies is affecting the Affordable Care Act Marketplaces and the millions of Americans who rely on them for coverage. The average deductible for an Affordable Care Act plan has reached record highs after jumping more than $1,000 between 2025 and 2026. This has resulted in estimates that the marketplace enrollment could fall by 5 million people, or 21.5%, as Americans fail to pay their premiums.
Our Insights
Fueled By Experts Across Our HMA Companies
Health Management Associates
Webinar Replay – ACA Enrollment Declines: Implications and Options for State and Federal Policymakers
Recent and future policy changes are reshaping the ACA market. A recent Wakely report finds that only 86% of ACA enrollees nationwide paid their first premium at the start of the year. Additionally, the 2027 Notice of Benefits and Payment Parameters (NBPP) was finalized, which will have additional implications for consumers, issuers, and other stakeholders. During this webinar, HMA’s ACA team had a policy-focused conversation on what these projected changes mean for marketplace dynamics, including impacts to risk pools, premiums, and issuer participation. The session explored emerging federal and state policy responses and offered insight into how today’s decisions may shape 2027 rates, plan offerings, and long-term market sustainability.
Registration Open: HMA 2026 Conference
Registration is open for HMA’s annual conference, US Healthcare 2026: Signals, Signs & Flashing Lights—Oct 5–7 in New Orleans. Join leaders from payers, providers, and the public sector to cut through the noise and focus on what’s working to address financial pressures, performance expectations, and AI and new technologies.
SAVE THE DATE: Fall State of Reform Health Policy Conference Dates Announced
State of Reform pulls together practitioners, thought leaders, and policymakers – each working to improve the healthcare system in their own way – into a unified conversation in a single place. These conferences are sure to be some of the most diverse statewide gatherings of senior healthcare leaders, and some of the most important events in state healthcare.
Join us for one of our fall events:
- September 3, 2026 – Southern California
- September 16, 2026 – Pennsylvania
- September 30, 2026 – Minnesota
- November 10, 2026 – North Carolina
- November 17, 2026 – Illinois
Wakely
From Premiums to Performance: Managing Risk in Self-Funded Health Plans
This brief is the second in a Wakely series outlining the fundamentals of self funding. It highlights key steps to successfully establish and manage a self funded health plan, with a focus on funding strategy, risk management, and cost control, and explores alternative funding approaches such as level funding, HRAs, captives, and trusts.
RFP Calendar
RFP Calendar
| Date | State/Program | Event | Beneficiaries |
|---|---|---|---|
| Date: February 2026 - DELAYED | State/Program: Illinois | Event: Awards | Beneficiaries: 2,400,000 |
| Date: June 24, 2026 | State/Program: Wisconsin LTC GSR 3 | Event: Awards | Beneficiaries: 56,000 (all GSR) |
| Date: Summer 2026 | State/Program: Illinois Foster Care | Event: RFP Release | Beneficiaries: 33,000 |
| Date: July 1, 2026 | State/Program: Hawaii Community Care Services | Event: Implementation | Beneficiaries: 5,500 |
| Date: July 28, 2026 | State/Program: Nevada Children's Specialty | Event: Awards | Beneficiaries: NA |
| Date: August 2026 | State/Program: Indiana | Event: RFP Release | Beneficiaries: 1,400,000 |
| Date: January 1, 2027 | State/Program: Illinois | Event: Implementation | Beneficiaries: 2,400,000 |
| Date: January 1, 2027 | State/Program: Nevada CO D-SNP | Event: Implementation | Beneficiaries: 88,000 |
| Date: January 1, 2027 | State/Program: Wisconsin LTC GSR 3 | Event: Implementation | Beneficiaries: 56,000 (all GSR) |
| Date: January 1, 2027 | State/Program: Illinois Tailored Care Management Program | Event: Implementation | Beneficiaries: 22,400 |
| Date: July 1, 2027 | State/Program: Nevada Children's Specialty | Event: Implementation | Beneficiaries: NA |
| Date: January 1, 2028 | State/Program: Wisconsin LTC GSR 4,6 | Event: Implementation | Beneficiaries: 56,000 (all GSR) |
| Date: Fall 2027 | State/Program: Oregon | Event: RFP Release | Beneficiaries: 1,200,000 |
| Date: 2028 | State/Program: North Carolina | Event: RFP Release | Beneficiaries: 2,200,000 |
| Date: 2029 | State/Program: California | Event: RFP Release | Beneficiaries: NA |