2026 Open Enrollment Checklist
To prepare for open enrollment, employers that sponsor health plans should be aware of compliance changes affecting the design and administration of their plans for plan years beginning on or after Jan. 1, 2026.
ACA Affordability Standard
The ACA requires ALEs to offer affordable, minimum-value health coverage to their full-time employees (and dependents) or risk paying a penalty to the IRS. This employer mandate is also known as the “pay-or-play” rules. An ALE is an employer with at least 50 full-time employees, including full-time equivalent employees, during the preceding calendar year.
An ALE’s health coverage is considered affordable if the employee’s required contribution for the lowest cost self-only coverage that provides minimum value does not exceed 9.5% (as adjusted) of the employee’s household income for the taxable year. For plan years beginning in 2025, the adjusted affordability percentage is 9.02%. On July 18, 2025, the IRS announced that the affordability percentage will increase to 9.96% for plan years beginning in 2026. This is a significant increase from the affordability percentage for 2025 and the highest this percentage has ever been. As a result, employers may be able to increase employees’ health coverage contributions for 2026 while still meeting the adjusted affordability percentage.
ALEs should take the following step for the 2026 plan year:
Confirm that at least one of the health plans offered to full-time employees satisfies the ACA’s affordability standard (9.96%). Because an employer generally will not know an employee’s household income, the IRS has provided three optional safe harbors that ALEs may use to determine affordability based on information that is available to them: the Form W-2 safe harbor, the rate-of-pay safe harbor and the federal poverty line safe harbor.
Out-of-Pocket Maximum
The ACA requires non-grandfathered health plans and health insurance issuers to comply with annual limits on total enrollee cost sharing for essential health benefits (EHB). This type of cost-sharing limit is commonly referred to as an out-of-pocket maximum (OOPM). The OOPMs for EHB for plan years beginning on or after Jan. 1, 2026, are $10,600 for self-only coverage and $21,200 for family coverage.
The ACA’s OOPM for self-only coverage applies to each individual, regardless of whether the individual is enrolled in self-only coverage or family coverage. This requires health plans and issuers to embed an individual OOPM in family coverage if the family OOPM is greater than the ACA’s OOPM for self-only coverage ($10,600 for 2026 plan years).
Also, to be compatible with HSA contributions, HDHPs must comply with lower limits on OOPMs.
With these requirements in mind, employers should take the following steps:
- Review the health plan’s OOPMs to ensure they comply with the ACA’s limits for the 2026 plan year;
- Determine if the health plan’s OOPM for family coverage is greater than the ACA’s OOPM for self-only coverage ($10,600for 2026 plan years). If it is greater, make sure the health plan embeds an individual OOPM for family coverage that is not more than $10,600; and
- If the health plan is an HDHP, confirm that it complies with the lower limits on OOPMs. For the 2026 plan year, the OOPMs for HDHPs are $8,500 for self-only coverage and $17,000 for family coverage
Preventive Care Benefits
The ACA requires non-grandfathered health plans and issuers to cover a set of recommended preventive services without imposing cost-sharing requirements, such as deductibles, copayments or coinsurance, when in-network providers provide the services. The recommended preventive care services covered by these requirements are:
- Evidence-based items or services with an A or B rating in recommendations of the U.S. Preventive Services Task Force;
- Immunizations for routine use in children, adolescents and adults recommended by the Advisory Committee on Immunization Practices;
- Evidence-informed preventive care and screenings in guidelines supported by the Health Resources and Services Administration (HRSA) for infants, children and adolescents; and
- Other evidence-informed preventive care and screenings in HRSA-supported guidelines for women.
Health plans and issuers are required to adjust their first-dollar coverage of preventive care services based on the latest preventive care recommendations. In general, coverage must be provided for a newly recommended preventive health service or item for plan years beginning on or after the one-year anniversary of when the recommendation was issued. For example, for plan years beginning after Dec. 30, 2025, health plans and issuers must expand their first-dollar coverage for preventive care for women to include additional breast cancer imaging or testing that may be required to complete the initial mammography screening process. In addition, health plans and issuers must cover patient navigation services for breast and cervical cancer screening without cost sharing.
Before the beginning of the 2026 plan year, employers should take the following step:
- Confirm the health plan covers the latest recommended preventive care services without imposing any cost sharing when the care is provided by in-network providers.
Download the full PDF here – 2026 Open Enrollment Checklist
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