The federal regulatory process may seem far removed from the exam room, but regulatory guidance and rules have a direct impact on whether patients can access quality, affordable health care. The recent decision by the Centers for Medicare & Medicaid Services (CMS) to maintain the 35% Essential Community Provider (ECP) contracting requirement for Marketplace plans demonstrates that participation in the federal rulemaking process can influence policies affecting the more than 52 million patients Community Health Centers (CHCs) serve. Even during periods of uncertainty, well-supported stakeholder feedback can shape final policy decisions and help protect access to care. The recent 2027 Notice of Benefit and Payment Parameters (NBPP) final rule, a regulation that sets standards for Marketplace plans, Exchanges, issuers, agents, brokers, and web-brokers, demonstrates how participating in the regulatory process can shape federal policy and protect CHC patients’ access to care.
A Win for CHCs and Their Patients
Earlier this year, the CMS proposed reducing the percentage of available ECPs that Marketplace plans must contract with from 35% to 20%. ECPs are facilities and providers that serve low-income, medically underserved, and populations with limited access to health care. Established under the Affordable Care Act (ACA), the ECP requirement helps ensure Marketplace plans include safety-net providers and prevents narrow networks from excluding the providers many patients rely on for care.
CHCs are designated as ECPs because of their unique mission and role in the healthcare system. Nearly 90% of CHC patients have incomes below 200% of the Federal Poverty Level (FPL), and CHCs care for one in five uninsured individuals nationwide. By providing comprehensive primary care, behavioral health, dental services, and other essential supports regardless of a patient’s ability to pay, CHCs serve as a critical access point in rural, suburban, urban, frontier, and island communities nationwide.
In response to the proposal, NACHC submitted a comment letter to raise concerns that lowering the threshold could weaken provider networks, disrupt continuity of care, and make it more difficult for patients to access trusted community providers. Nearly a dozen stakeholders, including Primary Care Associations (PCAs), CHCs, and other stakeholders across the country, joined the effort and utilized NACHC’s template comment letter to amplify the impact these changes would have within their communities.
CMS received over 2,500 comments on the proposed changes and ultimately agreed. The agency cited widespread stakeholder concerns and opted to maintain the 35% ECP contracting threshold:
Your Voices Prevailed!
This outcome directly protects access to care and serves as a reminder that participation in the federal rulemaking process can influence policies that impact the 52 million patients CHCs serve. Even during periods of uncertainty, federal agencies continue to consider stakeholder feedback, and well-supported comments can influence final policy decisions. By maintaining the 35% ECP contracting requirement, CMS preserved an important safeguard that helps ensure Marketplace plans continue to include community-based providers, like CHCs, serving low-income and medically underserved populations.
Strong Marketplace networks are essential to maintaining access to affordable, comprehensive care. At a time when the nation faces a projected shortage of up to 70,000 primary care physicians by 2037, CHCs are helping close the gap by serving more than 52 million patients and expanding access to care in medically underserved communities nationwide. CMS’ decision shows that the collective voices of CHCs, patients, and other partners can shape federal policy and protect access to care for the communities that need it most.
Other Important Marketplace Changes for CHCs
While the preservation of the ECP threshold is a major victory, several other finalized policies in the 2027 NBPP could create new barriers for CHC patients:
- Increased Eligibility Verification Requirements: CMS finalized several new income and Special Enrollment Period (SEP) verification requirements, which could create additional challenges for eligible individuals seeking coverage. Patients with fluctuating incomes, multiple jobs, seasonal employment, or difficulty obtaining income documentation may experience delays in coverage or require additional enrollment assistance.
- Marketplace Affordability Challenges: For low-income patients, Advanced Premium Tax Credits (APTCs) are essential to making Marketplace monthly premiums more affordable while elevating comprehensive coverage. The final rule tightens enforcement of APTC reconciliation requirements, meaning individuals who fail to file and reconcile their tax credits could lose access to financial assistance more quickly than before. As a result, more patients may become uninsured or underinsured, increasing demand for care and financial assistance at CHCs.
- Adult Dental Coverage Restrictions: CMS also finalized a policy that prevents states from including routine adult dental services as an Essential Health Benefit (EHB) beginning in 2028. This change may limit future expansion of Marketplace dental coverage and reduce access to oral health services for some CHC patients.
For more details on the final provisions, review NACHC’s 2027 NBPP factsheet.
Regulatory Engagement Is Crucial
The 2027 NBPP final rule offers an important reminder: federal policies are not predetermined. The decision to maintain the 35% ECP contracting threshold for Marketplace plans reflects the impact of strong stakeholder engagement and the value of sharing real-world experiences with policymakers. CHCs and PCAs brought the proposal’s real-world consequences to life, helping CMS understand how the change could affect patient access, provider networks, and continuity of care.
As NACHC continues advocating on issues ranging from Marketplace coverage to Medicaid and federal funding policies, we encourage members to continue sharing patient stories, operational challenges, and frontline experiences. Whether through NACHC’s comment letter templates, Regulatory Affairs Office Hours, or other engagement opportunities, your insight helps ensure policymakers understand how proposed changes affect patients and the communities CHCs serve.
Together, we can continue championing policies that expand access, reduce barriers to care, and support the vital role CHCs play in improving health outcomes for millions of patients.