2026 Affordable Care Act (ACA) Individual and Small Employer Form and Rate Filing Instructions

1 BULLETIN 25-1 Date: January 2, 2025 To: Insurers, Nonprofit Health Service Plans, Health Maintenance Organizations and Dental Plan Organizations Re: 2026 Affordable Care Act (“ACA”) Individual and Small Employer Form and Rate Filing Instructions The purpose of this Bulletin is to provide guidance to insurers, nonprofit health service plans, health maintenance organizations and dental plan organizations (“carriers”) regarding filing requirements for the individual and small employer form and rate filings for plan or policy years beginning on or after January 1, 2026. Form and Rate Filing Deadlines The rate and form filing deadlines for the individual and small employer health benefit plans are as follows:  Individual health benefit plans sold on and off the Exchange for the 2026 policy year: o Forms—Monday, March 3, 2025; o Rates—Monday, May 19, 2025;  Small employer health benefit plans sold on and off the Exchange: o Forms—Tuesday, April 1, 2025; o Rates— Monday, May 19, 2025;  Individual stand-alone dental plans forms and rates to be sold on the Exchange— Thursday, May 1, 2025; and  Small employer stand-alone dental plans forms and rates to be sold on the Exchange— Thursday, May 1, 2025. MARIE GRANT Acting Commissioner JOY Y. HATCHETTE Deputy Commissioner WES MOORE Governor ARUNA MILLER Lt. Governor 200 St. Paul Place, Suite 2700, Baltimore, Maryland 21202 1-800-492-6116 TTY: 1-800-735-2258 www.insurance.maryland.gov 2 General Requirements The essential health benefits will remain basically the same as for all prior years since 2017. The instructions for required benefits and exclusions described in Bulletin 15-33, dated December 10, 2015, will continue to apply to the 2026 plans, except for those benefits and exclusions that are determined to be presumptively discriminatory as discussed in Bulletin 23-5. The following requirements apply to the form filings: 1. For health benefit plans, forms and rates should be submitted in SEPARATE filings by their due dates shown above. For the form filings, the SERFF Filing Type is Form. For rate filings, the SERFF Filing Type is Rate. 2. Variability in cost-sharing, such as copayment amounts, coinsurance percentages or deductible amounts, will not be permitted. Instead, carriers are required to file a separate schedule of benefits form for each benefit design. 3. Individual and small employer form filings may not be combined under the same SERFF tracking number, but are required to be submitted under separate SERFF tracking numbers. 4. Each form filing for a health benefit plan is required to include: a. Identification of where the plan will be sold (i.e., in the Exchange, outside the Exchange, or both); b. Identification of the coverage level for each benefit design for a health benefit plan that is not a catastrophic plan (i.e., bronze, silver, gold, platinum); c. A separate contract or schedule for each plan design that the carrier intends to offer, except that the same schedule should be used for an on-Exchange plan and the “mirrored” off-Exchange version of the same plan (carriers are encouraged to use the same schedule in this situation to expedite the review process); d. A copy of the screen prints of each plan's AV calculator output, to demonstrate the actuarial value of each plan design determined in accordance with 45 CFR §156.135 using the AV calculator developed and made available by HHS. The copy of the screen prints should be submitted with the form filing using the 2026 actuarial value calculator which has been finalized by CMS. A copy of the screen prints should also be submitted with the rate filing. e. For individual health benefit plans, identification of the forms that will be used to provide coverage to those individuals who qualify for the cost-sharing reductions of the ACA or corresponding federal regulations.1 Additionally, for each cost-sharing reduction plan variation, the corresponding standard plan design must be clearly identified; 1 See § 1402 of the Affordable Care Act; 45 CFR § 155.1030; and 45 CFR § 156.420. 3 f. Certification that the health benefit plan’s prescription drug benefit complies with 45 CFR § 156.122 based on the information provided in the 2017-2026 EHB Benchmark Plan Information summary document provided by CMS and the version of the CMS Essential Health Benefits Rx Crosswalk Methodology that is current as of the date of the certification; and g. Documentation of compliance with the Mental Health Parity and Addiction Equity Act (MHPAEA) regulations as found in 45 CFR §§ 146.136 and 146.137.  The documentation is required to include an actuarial demonstration of how each financial requirement applicable to a mental health or substance use disorder benefit in the plan design is no more restrictive than the predominant financial requirement of that type that applies to substantially all of the medical/surgical benefits in the same classification.  The documentation should include a clear description of the methodology used by the carrier to determine the dollar amount of all plan payments for the substantially all/predominant analysis. For additional information, carriers should review the guidance provided by the Departments of Labor, Health and Human Services, and the Treasury in FAQs about Affordable Care Act Implementation Part 31, Mental Health Parity Implementation, and Women’s Health and Cancer Rights Act Implementation, Q8, published April 20, 2016, and FAQs about Affordable Care Act Implementation Part 34 and Mental Health and Substance Use Disorder Parity Implementation, Q3, published October 27, 2016.  The documentation is required to include a comparative analysis of all Non- Quantitative Treatment Limitations (“NQTLs”) that are shown in the filed forms, along with all the information required by Division BB, Title II, Section 203 of the federal Consolidated Appropriations Act of 2021. The NQTL Analysis Report Template Form by the MIA under §15-144 of the Insurance Article, Annotated Code of Maryland, may be submitted to satisfy this requirement, with the applicable NQTLs shown in the forms substituted for the NQTL categories in the template. For additional information, carriers should review the guidance provided by the Department of Labor’s Mental Health Parity Self-Compliance Tool. Carriers should also review the guidance provided by the Departments of Labor, Health and Human Services, and the Treasury in FAQs about Mental Health and Substance Use Disorder Parity Implementation and the Consolidated Appropriations Act Part 45. The following requirements apply to health benefit plan rate filings. 1. Include reference in the Filing Description to the SERFF Tracking Number of the corresponding form filing. 2. For Individual market filings, submit two sets of actuarial memoranda and rates in the filing: 1) assuming that the expanded tax credits under ARPA will not be extended past 12/31/25, and 2) assuming the expanded tax credits under ARPA will be 4 extended through 2026. For the small group market, only one set of filing documents is required. 3. Submit at least the following documents for the scenario in which ARPA subsidies do not get extended past 12/31/25: Part I: Unified Rate Review Template; Part II: Written Description Justifying the Rate Increase; Part III: Actuarial Memorandum and Certification. For detailed requirements for each of these documents, please refer to the 2026 Unified Rate Review Instructions, which will be published by the Department of Health and Human Services. 4. Submit the screen prints of each plan's AV calculator output, to demonstrate the actuarial value of each plan design determined in accordance with 45 CFR §156.135 using the AV calculator developed and made available by HHS;2 5. Provide all rating factors and a demonstration that there are no factors not allowed by the ACA; 6. Provide a demonstration that the projected Medical Loss Ratio (MLR) standard of at least 80.0% is expected to be met; 7. Claims should be paid through March 31 and the current enrollment in the URRT should be enrollment as of April 30. Other items required for health benefit plan filings: 1. Please note that the Maryland Health Benefit Exchange (“Exchange”) limits the number of plans that may be offered on the Exchange to three per metal level.3 Therefore, each filing that includes forms to be used on the Exchange is required to include a list of the forms that will be sold on the Exchange in 2026 and a listing of any previously approved forms that will no longer be offered on the Exchange. The following requirements apply to Stand Alone Dental Plans filings. 1. Forms and rates must be submitted in the same filing using SERFF Filing Type: Form/Rate. If the filing is not submitted as a Form/Rate filing, it will be REJECTED. Substitution Rules MIA Bulletin 13-02, which was issued January 7, 2013, described in detail the many factors that were considered in making the determination that substitution of essential health benefits (“EHBs”) would not be permitted in the individual and small employer markets for 2014 and that the approach would be reassessed for the future. The approach has been reassessed for 2026 and for substantially the same reasons described in MIA Bulletin 13-02, it has been determined that 2 If a health benefit plan’s design is not compatible with the AV calculator, the carrier shall submit actuarial certification using the chosen methodology in the rule, 45 CFR § 156.135(b 3 See MHBE Letter to Issuers dated February 26, 2024. 5 substitution of EHBs will not be permitted in the individual and small employer markets for 2026. Questions about this Bulletin may be directed to the Life/Health Section of the Maryland Insurance Administration at 410-468-2170. MARIE GRANT Acting Commissioner By: Signature on Original David Cooney Associate Commissioner Life and Health