The U.S. Department of Health and Human Services (HHS) issued final regulations designed to strengthen the integrity of the Affordable Care Act (ACA) Health Insurance Marketplace and adjust affordability standards that could indirectly impact employer health plans. While many provisions target insurers and the Exchanges themselves, certain changes affect employers, brokers, and HR teams administering employee benefits.
Key Updates for Employers and HR Teams
- 2026 Cost-Sharing Limits Increased
Beginning in 2026, the maximum annual out-of-pocket limits for non-grandfathered plans are rising to $10,600 for self-only coverage and $21,200 for family coverage. This supersedes the previously announced limits of $10,150 and $20,300. Employers offering high-deductible health plans (HDHPs) or other ACA-compliant coverage should factor these increased limits into future plan designs.
- Tightened Exchange Enrollment and Income Verification Rules
HHS is introducing new requirements aimed at reducing improper Exchange enrollments, particularly in light of temporary premium subsidy expansions during the COVID-19 pandemic. Notable changes include:
- More rigorous income verification processes for individuals applying for Exchange subsidies.
- Shortened timeframes to resolve income inconsistencies during enrollment.
- Pre-enrollment verification for many Special Enrollment Periods (SEPs) starting with the 2026 plan year.
- Automatic re-enrollment of certain Exchange participants with a $5 minimum monthly premium unless they confirm eligibility details.
These stricter rules may make it more difficult for employees to qualify for subsidized Exchange coverage in some cases, which could indirectly affect employer health plan participation rates.
- DACA Recipients Ineligible for Exchange Coverage
Effective August 24, 2025, individuals with Deferred Action for Childhood Arrivals (DACA) status will no longer be considered “lawfully present” for purposes of enrolling in Exchange plans or receiving subsidies. This reverses a short-lived policy expansion from earlier this year.
- Essential Health Benefits (EHB) Changes for 2026
For non-grandfathered individual and small group market plans, certain sex-trait modification procedures are being excluded from EHB requirements starting with the 2026 plan year. While states can still mandate coverage of these procedures, they will no longer be classified as federally required EHBs. Employers should monitor whether these state or federal updates affect coverage expectations, especially if offering fully insured small group plans.
- Open Enrollment Periods Standardized
Beginning with the 2027 plan year, Exchanges must set annual Open Enrollment Periods (OEP) that begin no later than November 1 and end no later than December 31, with a maximum duration of nine weeks. The federally facilitated Exchange OEP will continue to run from November 1 through December 15. This timing better aligns with many employer-sponsored health plan enrollment periods, which could reduce confusion for employees exploring coverage options.
Bottom Line for Employers
While these regulations largely focus on the ACA Exchanges and insurers, the changes to affordability thresholds, enrollment verification, and subsidy eligibility may affect employee coverage decisions, employer compliance strategies, and plan design considerations. HR and benefits teams should consult with their advisors to assess any indirect impacts on group health plan offerings in the coming years.
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This article is for informational purposes only and is not intended as legal, tax, or benefits advice. Readers should not rely on this information for taking (or not taking) any action relating to employment, compliance, or benefits. Always consult with a qualified professional before making decisions based on this content.
