ACA: Changes to Essential Health Benefits
The U.S. Department of Health and Human Services (HHS) has issued the 2027 Notice of Benefit and Payment Parameters (NBPP) Final Rule, which includes significant changes affecting essential health benefits (EHBs), state-mandated benefits, and Marketplace coverage under the Affordable Care Act (ACA).
While insurance carriers generally handle legal compliance for fully insured plans, employees may still have questions for their employer about changes to plan coverage. For self-funded and large group plans—even those that use a third-party administrator (TPA)—employers remain responsible for understanding the legal limits of plan design and applicable ACA compliance requirements.
Notable Changes
Changes that employers should be aware of for plan years beginning in 2027 include the following:
Routine adult dental services: The final rule reverses prior guidance that would have allowed routine non-pediatric dental services (i.e., adult dental benefits) to be treated as EHBs. Under the final rule, issuers cannot include routine adult dental services as EHBs.
Premium tax credit and Marketplace verification changes: The final rule revises certain Marketplace eligibility, premium tax credit (PTC), and verification procedures. These changes may affect employees purchasing individual market coverage, including employees participating in individual coverage health reimbursement arrangements (ICHRAs) or qualified small employer health reimbursement arrangements (QSEHRAs).
Applicability to Group Health Plans
The following coverage requirements remain generally unchanged:
Small group fully insured plans must continue to cover all state-defined EHBs.
Large group fully insured plans and self-funded plans are not required to cover all EHBs, but if they cover EHBs, ACA rules regarding cost-sharing limits and annual and lifetime dollar limits continue to apply.
Action Items:
Employers should work with their carriers, brokers, or TPAs to do the following:
Determine whether plan communications or participant materials need to be updated, including any references to routine adult dental services as EHBs.
Monitor how Marketplace eligibility and premium tax credit verification changes may affect employees purchasing individual market coverage, including employees participating in ICHRAs or QSEHRAs.