HR7164-119

What This Bill Does

The Capping Costs for Consumers Act of 2026 changes both cost-sharing reductions and premium assistance in ACA marketplaces. For plan years beginning on or after January 1, 2028, cost-sharing reduction references that currently operate through silver-level coverage are applied as if they referred to gold-level coverage. The bill keeps pre-2028 rules for households above 150 percent and up to 250 percent of the poverty line, including 87 percent, 73 percent, and 70 percent plan-share levels depending on income, but beginning in 2028 expands the 87 percent plan-share level to households above 150 percent and up to 300 percent of poverty and creates an 85 percent plan-share level for households above 300 percent and up to 400 percent of poverty. It appropriates such sums as necessary for cost-sharing-reduction payments. It also updates Basic Health Program benchmark language and Internal Revenue Code section 36B so, after 2027, premium assistance is determined using the applicable second-lowest-cost gold plan rather than the second-lowest-cost silver plan.

Who Benefits and How

Marketplace enrollees with incomes from 150 to 400 percent of the poverty line benefit from lower deductibles, copayments, coinsurance, and potentially richer benchmark coverage beginning in 2028. Enrollees between 150 and 300 percent of poverty benefit from an 87 percent actuarial-value level, while those between 300 and 400 percent benefit from an 85 percent level. Basic Health Program enrollees and premium-tax-credit recipients benefit because gold-plan benchmarks can increase subsidy support. Hospitals and clinics may benefit if patients face lower out-of-pocket costs and are less likely to delay care.

Who Bears the Burden and How

Federal taxpayers and federal revenue collections bear the cost of higher premium credits and cost-sharing-reduction payments. HHS, CMS marketplace staff, Treasury, and the Internal Revenue Service must update plan rules, benchmark calculations, payment systems, forms, and guidance. Health insurers must redesign silver and gold plan pricing, actuarial-value calculations, marketplace filings, and cost-sharing-reduction administration. State-based marketplaces and Basic Health Program administrators must update eligibility systems and consumer notices.

Key Provisions

• Expands ACA cost-sharing-reduction rules from silver-level coverage to gold-level coverage beginning in 2028.
• Provides an 87 percent actuarial-value level for households above 150 percent and up to 300 percent of poverty beginning in 2028.
• Provides an 85 percent actuarial-value level for households above 300 percent and up to 400 percent of poverty beginning in 2028.
• Appropriates such sums as necessary for cost-sharing-reduction payments.
• Changes Basic Health Program benchmark references from silver to gold after 2027.
• Changes premium tax credit calculations to use the second-lowest-cost gold plan for taxable years after 2027.