CMS is describing the 2027 Payment Notice as a win: lower user fees, less fraud, more state control. For a hospital system's revenue cycle, the same rule reads differently. Your patient access team is already spending more time chasing coverage status than it did a year ago; starting in 2027, that work gets harder while the coverage behind it gets thinner.
On May 15, 2026, CMS finalized the 2027 Payment Notice, the annual rule that governs ACA Exchange plans (see the CMS fact sheet). The table below lists the nine provisions that matter most. The remainder of this guide translates the ones that hit your revenue cycle hardest into actions you can take starting this quarter.
Provision |
Detail |
| 1. SEP eligibility verification | Reinstates pre-enrollment verification for at least 75% of new Special Enrollment Period sign-ups starting in 2027. Additional income documentation required for very low-income enrollees and those without corroborating tax data.
|
| 2. APTC eligibility narrowed | Starting in 2027, premium tax credit eligibility limited to citizens and a limited set of lawful immigrants, excluding refugees, asylum recipients, and others with lawful status. Aligns with One Big Beautiful Bill Act (H.R. 1).
|
| 3. Low-income SEP ban continues | Ban on the low-income SEP for households at 150% FPL extends beyond 2026.
|
| 4. Federal Exchange user fees |
Reduced to 1.9% for FFE and 1.5% for SBE-FPs, down from 2.5% and 2.0% in 2026.
|
| 5. Plan design flexibility | Eliminates the requirement that federal-exchange issuers offer standardized plan options; removes the cap on non-standardized plans. New pathway for non-network plans to be certified as QHPs — as early as plan year 2027 for state-based exchanges, and no later than plan year 2028 for the federal exchange
|
| 6. Catastrophic plan expansion | Allows issuers to offer catastrophic plans with terms up to 10 consecutive plan years. Expands hardship exemption eligibility for enrollment in catastrophic coverage.
|
| 7. EHB restrictions | Prohibits issuers from including routine non-pediatric dental services as Essential Health Benefits. Beginning plan year 2028, states must defray the cost of state-mandated benefits in addition to EHB.
|
| 8. Broker & marketing standards | Standardized broker eligibility application and consent form (effective 2028); codified list of banned marketing practices (cash inducements, false zero-premium claims, enrollment timeline misrepresentations).
|
| 9. State authority expansion | Provisions allow states to strengthen oversight over Exchanges by tailoring certification reviews to local market conditions. |
Marketplace enrollment already fell roughly 5% to 23.1 million in 2026 after enhanced premium tax credits expired at the end of 2025. KFF projects an additional loss of about 4.8 million enrollees as those subsidies fully phase out.
That matters because the people who leave are often the healthy ones. The silver-plan share dropped from 57% to a record-low 43%, bronze jumped from 30% to 40%, and the average Marketplace deductible rose 37% – from roughly $2,800 to $3,800. (HFMA analysis)
A sicker, higher-deductible risk pool means more patient financial responsibility landing on your balance sheet. The 2027 rule accelerates that trend rather than cushioning it.
CMS is correct in stating that the rule lowers some costs. As the table above shows, it cuts federal Exchange user fees to 1.9% for FFEs and 1.5% for SBE-FPs. Those savings flow to issuers and, in theory, to premiums.
But lower premiums are not lower cost for healthcare providers. The savings sit with plans and enrollees. The provider absorbs the other side of the rule: higher deductibles, more coverage gaps, and more uninsured patients – costs that show up as bad debt and uncompensated care.
The rule tightens the front door while thinning the coverage behind it. Both effects hit patient access – the point where coverage is verified – long before they appear in a quarterly payer-mix report.
HCA Healthcare assumed 80–85% of patients losing exchange coverage would become uninsured; its data now shows the migration is closer to one-for-one. That revision pushed HCA's full-year exchange headwind to $1.0–$1.2 billion for 2026 and – nearly double the $600–$900 million it projected in April.
Three mechanisms drive it. First, CMS reinstates pre-enrollment verification for at least 75% of new Special Enrollment Period sign-ups, so more patients arrive mid-verification. Second, premium tax credit eligibility narrows to citizens and a limited set of lawful immigrants, aligning with the One Big Beautiful Bill Act (H.R. 1). Third, the low-income SEP ban at 150% of the federal poverty level continues past 2026.
Standard eligibility workflows assume coverage is either active or not. These provisions create a large middle band – pending, ineligible-for-subsidy, or newly uninsured – that most front-end scripts don't handle.
The nine provisions in the table above are the what; the five moves below are where your team spends its time. Each maps to one or more provisions, ordered by revenue cycle workload rather than by the rule's own sequence.
Assume any SEP enrollee could be mid-verification at the point of service. If coverage shows pending, route to a financial counselor before scheduling non-urgent care rather than assuming denial. Build a status code for "SEP pending" so these accounts don't silently age into bad debt.
The narrowed subsidy rules will push refugees, asylees, and other previously eligible patients toward full-price or no coverage. If a patient's status suggests APTC ineligibility, trigger a self-pay and charity-care screening early, not after the first claim is denied.
The rule lets issuers offer catastrophic plans with terms up to 10 consecutive years and expands hardship-exemption eligibility. Treat catastrophic enrollees like high-deductible patients: verify remaining deductible up front, and offer payment plans before service where policy allows.
Non-network plans may be certified as QHPs as early as plan year 2027 in states operating their own exchanges, and no later than plan year 2028 on the federal exchange. When that lands, out-of-network encounters expand materially. Start tagging any non-network product in your area today so your out-of-network dispute-resolution workflow isn't caught flat-footed.
The rule restores greater authority to states over certification and oversight, so rules will diverge state by state. If you operate across states, assign someone to monitor each Exchange's local rules; one national assumption will no longer hold.
For many providers, front-end staffing is already stretched, and eligibility data from Exchanges is often incomplete at the point of service. Layering five new workflows onto a lean patient access team is not realistic in a single quarter.
Triage. If you do only one thing, do move #1 – the SEP verification re-script – because it touches the largest volume of patients starting in 2027. Add moves #2 and #3 next quarter. Move #4 up if you operate in state-based exchange states, where non-network plans could appear as early as 2027; otherwise treat #4 and #5 as planning items and revisit them when rate filings clarify who's actually offering non-network plans.
One development to build into your planning: The rule is already in active litigation – and courts have acted. A federal judge in Maryland has stayed eight provisions of the 2027 rule, a coalition of cities, counties, physicians, and small businesses filed suit on June 3, 2026, and on July 31 a group of 22 states filed a separate challenge in the Northern District of California. Several verification-related provisions may be enjoined for 2027 while surviving for 2028, because H.R. 1 codifies similar requirements statutorily. Plan for the rule as written, but reconcile your 2027 workflows against the current stay list before hard-coding anything
One caveat worth watching: Parts of the rule face ongoing litigation that could shift implementation timelines on some provisions. Plan for the rule as written, but keep an eye on the docket before hard-coding anything for 2028.
The provisions above all point in one direction: more coverage ambiguity, more out-of-network encounters, and more complex claims landing on your team. That is exactly the specialized, hard-to-adjudicate volume EnableComp exists to resolve.
If the non-network QHP pathway and shifting Marketplace mix are on your radar, let's talk about how EnableComp can absorb the complex-claims load before it hits your bad-debt numbers.
Gordon Jaye, MPH, MScPM, is the Senior Vice President of Solution Engineering at EnableComp and a Six Sigma Black Belt. He brings extensive healthcare-operations leadership focused on optimizing patient access, patient satisfaction, and front-end revenue cycle efficiency. Gordon specializes in strategies that improve patient flow, reduce wait times, and streamline intake through technology and process improvement. He is known for driving transformational change with rigorous financial oversight.
_____
The 2027 Payment Notice is CMS's annual rule governing ACA Exchange (Marketplace) plans, finalized on May 15, 2026. It covers plan design, verification requirements, subsidy eligibility, and Exchange oversight for the 2027 plan year, including provisions on Special Enrollment Period verification, premium tax credit eligibility, catastrophic plan terms, and state authority over Exchange certification.
Starting in 2027, CMS reinstates pre-enrollment verification for at least 75% of new SEP sign-ups, with additional income documentation required for very low-income enrollees and those without corroborating tax data. This means more patients arriving at point of service with coverage still pending verification, rather than a clear active/inactive status.
The 2027 rule limits premium tax credit (APTC) eligibility to citizens and a limited set of lawful immigrants, excluding refugees, asylum recipients, and others with lawful status who previously qualified. This aligns with the One Big Beautiful Bill Act (H.R. 1) and will push some previously subsidized patients toward full-price coverage or no coverage at all.
The rule creates a new pathway for non-network health plans to be certified as Qualified Health Plans (QHPs). States running their own Exchanges can certify non-network QHPs as early as plan year 2027; the federal Exchange must do so no later than plan year 2028. For providers, this means a likely increase in out-of-network encounters once these plans reach the market.