ACA 2027 Final Rule Targets Sales and Marketing
- John A. Selby
- May 28
- 2 min read
John Selby
President, Rebellis Group
The Affordable Care Act (ACA) was passed in March 2010. At the time I was Sr. Director of Sales & Marketing for senior and consumer markets at Horizon Blue Cross Blue Shield of New Jersey. NJ had a thriving individual market that adopted ACA-type reforms in the early 1990s, and Horizon was the undisputed leader, so this transition was easier for us than other payers. The biggest changes were adapting to federal rules and, of course, building the Federal Marketplace interface.
We were also an experienced Medicare Advantage (MA) plan. In the more than four years we spent preparing for the ACA to go live, we expected CMS to model its ACA oversight, particularly for sales and marketing, on MA. Well, that time has finally come.
The 2027 Marketplace Final Rule includes expanded marketing and broker oversight and enrollment integrity scrutiny. Marketing materials that include misleading “zero-dollar” plan references or misrepresented enrollment deadlines, for example, are in CMS’s crosshairs.
To prepare, plans should be reviewing:
Third-party marketing oversight
Delegated compliance audits
Marketing material workflows
Broker monitoring processes
More significantly, perhaps, CMS is doubling down on enrollment integrity in the wake of reported unscrupulous broker tactics and income/eligibility manipulation. Newly-expanded SEP pre-enrollment verification requirements and additional income verification requirements when income is below 100% of the Federal Poverty Limit (FPL) are intended to protect tax dollars from being used fraudulently.
To operate compliantly, plans will need to assess the coordination between:
Enrollment operations
Eligibility vendors
Customer Service
Compliance
Plans should also expect more member complaints, appeals and grievances related to subsidy verification and potentially fewer effectuated enrollments.
The Final Rule also increased plans’ overall audit and compliance exposure, included major changes to product design flexibility, shifted authority back to states in several areas, finalized risk adjustment changes, will permit certain non-network Federally-Facilitated Exchange options, and removed the requirement that qualified health plans address health disparities within Quality Improvement strategies. (States that operate their own exchange may opt not to implement some of these changes if they are found to be unlawful under state law.)
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