Trump administration hits state small-group dental and fertility mandates

The Centers for Medicare & Medicaid Services and its parent department, the U.S. Department of Health and Human Services, discuss those topics in a new set of final benefits and payment paramhose topics in the final version of the ACA benefits and payment parameters notice for 2027 and later years.

CMS posted a preliminary version of the 1,121-page document packet Friday and expects to publish the packet in the Federal Register — an official government rulemaking publication — in the next few days.

What it means: If the changes in the new parameters document stick, fully insured major medical coverage — and self-insured plans that try to match the fully insured benefits plans' benefits — could be somewhat leaner and cheaper than originally expected.

Mechanics: The new final draft parameters notice regulations are based on a version proposed in February.

HHS Secretary Robert F. Kennedy Jr. signed the packet, and Dr. Mehmet Oz, the CMS administrator, approved the packet.

The packet includes the names of many contact people. Jeff Wu, Rogelyn McLean and Grace Bristol are the contacts for general information, and Brian Gubin is the contact person for agent, broker and web broker matters.

The mandates fight: The ACA uses a standard benefits package, the "essential health benefits" package, to administer the ACA public exchange and premium subsidy tax credit programs.

Each state can design its own EHB package, within a framework shaped by the ACA statutes and CMS regulations.

Each state must align its EHB package with a large "benchmark" plan, such as a state public employees' health plans.

Some states have tried to add fertility benefits, dental benefits and other benefits to their EHB packages both by imposing direct state benefits mandates and by requiring the plan used as the EHB benchmark to provide those benefits.

The EHB rules apply directly to individual major medical insurance and fully insured small-group major medical insurance.

Related: Small-group health plans face benefits shakeup as CMS targets state mandates

The new parameters notice establishes different EHB rules for 2027 and 2028.

In 2027, a state can make a state-mandated benefit part of the EHB package if the mandate was in place before Dec. 31, 2011; was adopted to meet federal requirements; or is part of the EHB-benchmark plan.

Starting in 2028, a state can still include a pre-2011 mandate or a mandate adopted to comply with federal requirements in the EHB package.

But a state can include an EHB-benchmark plan benefit in the EHB package only if the benchmark plan adopted the benefit voluntarily, or in compliance with federal requirements.

If a state made the benchmark plan offer the benefit, the state cannot then use the fact that the benchmark plan offers the benefit to put the benefit in the EHB package.

A state can still require major medical plans to offer additional benefits, but, if it does so, it must compensate the federal government for any extra ACA premium subsidy costs created by the additional benefits.

The change is similar to what CMS put in the February draft. The main difference is that the change is set to take place in 2028, rather than in 2027.

States have argued that the new rules reduce the the ability the ACA was supposed to give them to tailor standard health benefits packages to fit local needs.

Officials at HHS and CMS said letting states add benefits drives federal subsidy spending and increases the net cash cost of coverage for consumers and employers that do not qualify for the ACA premium subsidies.

The self-insured plan effect: CMS officials noted in the "preamble," or official introduction, to the final regulations that some members of the public have suggested that pushing some benefits out of the EHB package may affect employers' self-insurance health plans.

The ACA requires self-insured plans to cover any EHB items that they cover without imposing annual or lifetime benefits limits on the patients.

The ACA also imposes maximum annual out-of-pocket cost-sharing limits on any covered items that are part of the EHB package.

If a self-insured plan still covers items such as fertility services that are no longer part of the EHB package, then the ACA cost-sharing limit and rules for annual and lifetime spending limits may no longer to those services, commenters told CMS officials.

"We do not agree that this policy would enable plans to newly impose restrictions on coverage," CMS officials said in response to that argument. "We note that, to the extent a state repeals a state-required benefit that would otherwise be considered in addition to the EHB, and the benefit remains in the state's EHB-benchmark plan, such benefit would continue to be treated as EHB and therefore remain subject to applicable consumer protections."

Other changes: CMS officials have fleshed out and reworded existing ACA exchange plan agent and broker rules, such as rules that forbid producers from using AI-generated videos to imply that government officials or celebrities have endorsed them.

CMS officials have also shut down an option for HealthCare.gov to get training from outside firms, rather than from HealthCare.gov itself.

Only about 10% of agents and brokers were using the outside training vendors, and offering that option cost CMS $300,000 per year, officials said.

Proposals not adopted: Officials decided against moving ahead with a proposal that could have let states put outside web brokers in charge of providing ACA public exchange services in their jurisdictions.

Officials also skipped implementing some proposals related to catastrophic plan benefits.

ACA public exchange enrollment: The ACA exchange system served 25.2 million people in 2025.

CMS tightened ACA exchange enrollment rules for 2026, and a temporary ACA premium subsidy boost made available in response to the COVID-19 pandemic expired.

Originally, officials estimated that total enrollment level would fall to 17.7 million this year and to somewhere between 15.7 million and 16.5 million in 2027.

Sales for 2026 have been better than officials expected.

Officials are now saying that they think total enrollment for this year is about 18.9 million and that enrollment in 2027 will range from 16.9 million to 17.7 million.