United States Government Publishing Office publisher pbl distributor dst United States National Archives and Records Administration Office of the Federal Register author aut Government Organization text government publication eng FR Regulatory Information 2025_register executive 2025-01-15 article Part X Rules and Regulations D09002ee1cf41c3b7 D09002ee1cf41c921 United States Department of Health and Human Services originator org United States Government Agency or Subagency United States Office of the Secretary originator org United States Government Agency or Subagency This final rule includes payment parameters and provisions related to the HHS-operated risk adjustment and risk adjustment data validation (HHS-RADV) programs, as well as 2026 benefit year user fee rates for issuers that participate in the HHS-operated risk adjustment program and the 2026 benefit year user fee rates for issuers offering qualified health plans (QHPs) through Federally-facilitated Exchanges (FFEs) and State-based Exchanges on the Federal platform (SBE-FPs). This final rule also includes requirements related to modifications to the calculation of the Basic Health Program (BHP) payment; and changes to the Initial Validation Audit (IVA) sampling approach and Second Validation Audit (SVA) pairwise means test for HHS-RADV. It also addresses HHS' authority to engage in compliance reviews of and take enforcement action against lead agents of insurance agencies for violations of HHS' Exchange standards and requirements; HHS' system suspension authority to address noncompliance by agents and brokers; an optional fixed-dollar premium payment threshold; permissible plan-level adjustment to the index rate to account for cost-sharing reductions (CSRs); reconsideration standards for certification denials; changes to the approach for conducting Essential Community Provider (ECP) certification reviews; a policy to publicly share aggregated, summary- level Quality Improvement Strategy (QIS) information on an annual basis; and revisions to the medical loss ratio (MLR) reporting and rebate requirements for qualifying issuers that meet certain standards. 90 FR 4424 https://www.govinfo.gov/app/details/FR-2025-01-15/2025-00640 2025-00640 fr15ja25-29 RIN 0938-AV41 4120-01-P CMS-9888-F https://www.govinfo.gov/app/details/FR-2025-01-15/2025-00640 https://www.govinfo.gov/content/pkg/FR-2025-01-15/html/2025-00640.htm https://www.govinfo.gov/content/pkg/FR-2025-01-15/pdf/2025-00640.pdf 119 p. 4424 4542 90 FR 4424 Title 45 Part 153 45 CFR Part 153 Title 45 Part 155 45 CFR Part 155 Title 45 Part 156 45 CFR Part 156 Title 45 Part 158 45 CFR Part 158 RIN 0938-AV41 Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2026; and Basic Health Program; Federal Register Vol. 90, Issue RULE 2025-00640 X DEPARTMENT OF HEALTH AND HUMAN SERVICES Office of the Secretary 2025-01-15 CMS-9888-F 4120-01-P 2025-00640 Final rule.

This final rule includes payment parameters and provisions related to the HHS-operated risk adjustment and risk adjustment data validation (HHS-RADV) programs, as well as 2026 benefit year user fee rates for issuers that participate in the HHS-operated risk adjustment program and the 2026 benefit year user fee rates for issuers offering qualified health plans (QHPs) through Federally-facilitated Exchanges (FFEs) and State-based Exchanges on the Federal platform (SBE-FPs). This final rule also includes requirements related to modifications to the calculation of the Basic Health Program (BHP) payment; and changes to the Initial Validation Audit (IVA) sampling approach and Second Validation Audit (SVA) pairwise means test for HHS-RADV. It also addresses HHS' authority to engage in compliance reviews of and take enforcement action against lead agents of insurance agencies for violations of HHS' Exchange standards and requirements; HHS' system suspension authority to address noncompliance by agents and brokers; an optional fixed-dollar premium payment threshold; permissible plan-level adjustment to the index rate to account for cost-sharing reductions (CSRs); reconsideration standards for certification denials; changes to the approach for conducting Essential Community Provider (ECP) certification reviews; a policy to publicly share aggregated, summary- level Quality Improvement Strategy (QIS) information on an annual basis; and revisions to the medical loss ratio (MLR) reporting and rebate requirements for qualifying issuers that meet certain standards.

These regulations are effective on January 15, 2025. Jeff Wu, (301) 492-4305, Rogelyn McLean, (301) 492-4229, Grace Bristol, (410) 786-8437, for general information. 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Table of Contents: AE 2.7: GS 4.107: AE 2.106: KF70.A2 https://www.govinfo.gov/app/details/FR-2025-01-15 P0b002ee1cf41b37b 0097-6326 0042-1219 0364-1406 769-004-00000-9 000582072 f:fr15ja25 https://www.govinfo.gov/app/details/FR-2025-01-15 https://www.govinfo.gov/content/pkg/FR-2025-01-15/pdf/FR-2025-01-15.pdf https://www.govinfo.gov/content/pkg/FR-2025-01-15/xml/FR-2025-01-15.xml fdlp 3601 4584 DGPO 2025-01-15 2025-01-15 FR-2025-01-15 machine generated eng FR FR-2025-01-15 90 9