October 22, 2024
On October 8, 2024, CMS released the proposed Notice of Benefit and Payment Parameters Rule for 2026. This notice is issued annually preceding the applicable benefit year and, once final, adopts certain changes. Additionally, CMS issued Premium Adjustment Percentage and related guidance to inform the payment parameters for the 2026 benefit year. While the proposed rule primarily impacts the individual market and the Exchange, CMS’s Premium Adjustment Percentage and related guidance addresses certain ACA provisions and related topics that impact employer-sponsored group health plans. Below are the highlights.
Annual Cost-Sharing Limits. The ACA requires non-grandfathered group health plans to comply with an out-of-pocket maximum on expenses for essential health benefits. CMS proposes that this maximum annual limitation on cost-sharing for 2026 will be $10,150 for self-only coverage and $20,300 for family coverage (an increase from $9,200 and $18,400 for self-only/family coverage respectively in 2025).
Premium Adjustment Percentage and Payment Parameters. CMS announced the premium adjustment percentage for the 2026 benefit year as 1.6002042901 ($7,833/$4,895), which indicates an increase in employer-sponsored insurance premiums of approximately 60.0% over the period from 2013 to 2025. This premium adjustment percentage will also be used to index the Employer Mandate provision’s penalty amounts for the 2026 benefit year.
The proposed Notice of Benefit and Payment Parameters Rule proposes updates to marketplace requirements and includes provisions to address network adequacy, improve access to healthcare items and services (such as prescription drugs and adult dental benefits), and promote fair marketing standards. For further details of the specific proposed rule, please refer to the CMS Notice.
Once the regulations are finalized, employers should review them and implement any changes needed for the 2026 plan year.
PPI Benefit Solutions does not provide legal or tax advice. Compliance, regulatory and related content is for general informational purposes and is not guaranteed to be accurate or complete. You should consult an attorney or tax professional regarding the application or potential implications of laws, regulations or policies to your specific circumstances.
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