H.R. 7861 — Care Over Profits Act of 2026

This section increases the minimum medical loss ratio (MLR) requirement for health insurance issuers offering nongrandfathered coverage in the individual and small group markets to 85% (from 80%) of premium revenue that must be spent on medical claims and quality improvement activities. The change applies to plan years beginning on or after January 1, 2026. (As background, the MLR rule requires issuers not meeting the threshold to provide rebates to policyholders.)

This section imposes new civil and criminal penalties on agents and brokers for violations related to providing incorrect or false information under the Exchange eligibility verification program (42 U.S.C. 18081(h)(1)), which determines applicant eligibility for qualified health plans, premium tax credits, and cost-sharing reductions based on citizenship or lawful immigration status, income, and other factors. Specifically, it (1) subjects agents or brokers to a civil penalty of $10,000 to $50,000 per affected individual for negligence or disregard of rules in providing incorrect information; (2) subjects agents or brokers to a civil monetary penalty of up to $200,000 per affected individual, with procedures mirroring those under SSA section 1128A, for knowingly and willfully providing false or fraudulent information; and (3) imposes criminal penalties on such agents or brokers, including fines under 18 U.S.C. and imprisonment for up to 10 years, or both. The amendments apply to applications for plan years beginning on or after January 1, 2027.