In February, the Centers for Medicare & Medicaid Services (CMS) released a proposed regulation outlining a series of changes to the Affordable Care Act (ACA) insurance standards and Marketplace operations. The proposed Notice of Benefit and Payment Parameters (NBPP) for plan year 2027 follows a series of federal-level policy changes in 2025 affecting the ACA Marketplaces, including the expiration of enhanced premium tax credits, newly restrictive eligibility rules, and new paperwork burdens for consumers. Those changes, combined, are expected to reduce Marketplace enrollment by up to 57% and contributed to an average 21.7% individual market premium increase for 2026. This proposed rule would double down on many of the recent policy changes and, by CMS’ own estimates would reduce Marketplace enrollment by up to 2 million people and federal spending on premium tax credits by $10.4 billion in 2027. For a detailed summary of the proposed rule, see the Health Affairs Forefront articles here, here, and here.
Although CMS provided a short 30-day window for the public to comment on the NBPP, the agency received 1044 comments, almost 4 times the number of comments received on the 2026 proposed rule. CHIR reviewed a sample of comments from four stakeholder groups to better understand how these organizations view the impact of the proposed policy changes. This first blog in our 4-part series summarizes comments from a sample of health insurers, their representative associations, and brokers. Future blogs in our series will summarize comments from consumer and patient advocates, providers, and state-based Marketplaces (SBM) and insurance regulators. For this post, we reviewed comments submitted by:
America’s Health Insurance Plans (AHIP)
Association for Community Affiliated Plans (ACAP)
Blue Cross Blue Shield Association (BCBSA)
Centene
Elevance
HealthSherpa
National Association of Benefits and Insurance Professionals (NABIP)
Oscar Health
Sidecar Health Insurance Company
Insurers and brokers had mixed reviews of the policies proposed in this rule. Although all supported at least some provisions, several noted that the proposed rule was released relatively late compared to previous years, and the process for obtaining Marketplace plan certification for 2027 begins on April 16, 2026. This timeline makes it difficult, if not impossible, for insurers to adequately prepare for the many novel ideas floated in the NBPP. Several also cautioned CMS not to pursue certain policies until the effects of the expiration of enhanced premium tax credits and passage of H.R. 1, the 2025 budget reconciliation bill, are better understood. One insurer, Oscar Health, reminded CMS that one of the administration’s signature policy priorities, Individual Coverage Health Reimbursement Accounts (ICHRAs) “only work if the individual market works.”
Provisions Reversing Biden-era Marketplace and Insurance Standards
The proposed rule contains provisions that would roll back several policies implemented by the Biden administration, including federal standards and oversight of plan network adequacy, greater flexibility for states’ inclusion of state-mandated benefits in the essential health benefit (EHB) package, standardized plans and limits on non-standard plans in the federally facilitated marketplace (FFM), as well as Biden-era efforts to streamline the eligibility and enrollment experience for consumers.
Network adequacy standards and oversight
CMS proposes to lift current rules that require SBMs and SBMs on the federal platform (SBM-FP) to impose quantitative network adequacy standards that are at least as stringent as those set by the FFM. The agency would also lower the threshold for the number of essential community providers (ECP) that Marketplace insurers must include in their networks, and allow FFM states that met certain criteria to assess Marketplace plans for network adequacy.
The insurers in our sample were strongly supportive of deferring to states for network adequacy standards and oversight. AHIP for example noted that the current federal standards have forced member plans to add higher cost, lower quality providers, and increased their administrative burdens. Elevance expressed a common view among this stakeholder group, arguing that “[s]tates are best positioned to evaluate local provider networks and market conditions.” Centene, however, noted that they would need a “significant implementation runway” to prepare for varied network reporting requirements across the states in which they operate. AHIP and Elevance used their comment letters to express concerns about federal appointment wait time standards, noting that they have little ability to influence the appointments offered by their participating providers.
Most of the comments also supported lowering the standard for the inclusion of ECPs in plan networks, and allowing states to conduct their own ECP certification reviews. One exception was NABIP, which expressed concern that lowering the standards could “reduce meaningful access in communities where provider availability is already constrained.” AHIP and BCBSA, while supportive of a lowered standard and state-driven oversight, encouraged the FFM to maintain a minimum federal standard for the inclusion of ECPs.
Treatment of state-mandated benefits
CMS proposes that states be required to defray the cost of any state-mandated benefits that are: (1) required by the state after December 31, 2011; (2) applicable to the small-group and/or individual market; (3) specific to required care, treatment, or services; and (4) not required by the state to comply with federal standards.
The stakeholders in our sample universally supported this proposal, and further called on CMS to provide greater clarity on whether and how to determine whether a state-mandated benefit is subject to defrayal, and establish a process for resolving disputes. For example, Centene called on the agency to develop a centralized, CMS-determined “source of truth” regarding benefits that remain as EHB, noting that this would help insurers that operate in multiple states avoid inconsistent state interpretations. However, several of the commenters noted that states’ legislative sessions and plan filing timelines presented challenges to requiring defrayal for plan year 2027, and encouraged CMS to delay implementation until plan year 2028, at the earliest.
Standardized plan options and limits on non-standardized plans
CMS proposes to remove requirements that insurers in the FFM and in SBM-FPs offer standardized health plans. Although insurers could continue to offer such plans, they would no longer receive preferential display on HealthCare.gov. Further, the rule would remove current limitations on the number of non-standardized plans that insurers can offer at each metal level.
The insurers in our sample strongly supported both proposals, arguing that the standardized plans created by CMS did not meet consumers’ needs and the limits on non-standardized plans stifled innovative plan designs. However, although ACAP supported the reversal of these policies, they flagged concern that large insurers are “flooding the market” with look-alike plans, leaving consumers with “choice paralysis” because there are too many to choose from. The association called on CMS to establish a strong standard to ensure there is a “meaningful difference” between plan offerings. NABIP and Oscar encouraged the agency to instead invest in alternative tools and methods to improve consumer decision-making, such as better provider directories, network transparency, and better sorting and filtering of plan options on HealthCare.gov.
New documentation requirements for applicants with a data matching issue (DMI)
CMS proposes to newly require applicants to provide additional proof of income if external data sources suggest they have an income below 100% of the federal poverty level (FPL) or if tax data is unavailable for the applicant.
The insurers in our sample raised several concerns with this proposal. AHIP called for CMS to delay implementation until it could assess the impact of other recently adopted program integrity measures. “Layering additional verification before assessing the effectiveness of existing measures creates unnecessary burden for enrollees,” the association noted. ACAP further commented that healthy people are more likely to be deterred by additional red tape, “ultimately disadvantaging the risk pool.” Centene observed that “[i]ndividual market consumers are complex,” and often have income streams (hourly, seasonal, and tip-based) that have “a significant degree of variability.” Although BCBSA did not oppose the policy, it encouraged the agency, if it does finalize the proposal, to invest in ways to expand access to trusted third-party data sources in order to reduce the burdens on consumers.
All commenters, including Elevance, which was generally supportive of more robust income verification, urged CMS not to extend this policy to the SBMs. AHIP’s comment exemplified these stakeholders’ common view that SBMs “haven’t experienced the improper enrollments [that the FFM has] and imposing this on them is burdensome.”
New Policy Proposals
The proposed 2027 NBPP includes several novel policy ideas, including SBMs exclusively operated by web-brokers and insurers, the certification of plans with no provider network, and multi-year catastrophic plans with extremely high deductibles. CMS would also ask insurers to provide detailed reports relating to premium adjustments for unreimbursed cost-sharing reduced (CSR) plans, a possible precursor for federal limits on the practice of “silver loading.” Lastly, the agency sought comment on whether and how it should make adjustments to the ACA’s medical loss ratio (MLR) standards.
State-based Marketplaces and “Enhanced Direct Enrollment”
CMS proposes to allow states to establish an SBM that eliminates a centralized eligibility and enrollment platform and instead leverages web-brokers to process Marketplace enrollments. Most commenters in our sample expressed strong concerns about this proposal. Two exceptions were Health Sherpa and Oscar, both of whom supported allowing states to opt out of offering a centralized enrollment platform. However, Health Sherpa cautioned that states should be required to provide plan data consistent with the current Public Use Files, retain control over consumer casework, and provide oversight and enforcement of the agents and brokers authorized to write business for the Marketplace. Oscar encouraged CMS to ensure that states guarantee operational readiness, with rigorous testing, before transitioning to an EDE model.
The other organizations in our sample urged CMS not to adopt this proposal. AHIP argued that an EDE-only Marketplace “could risk eroding consumer trust,” mislead consumers, and undermine program integrity. Some of the insurers noted that many web-brokers offer non-ACA-compliant products, which could confuse consumers who may believe such products have met the same standards as Marketplace plans. AHIP, for example, counseled that if CMS finalizes its proposal, it should prohibit EDE platforms from including non-ACA-compliant products on their websites.
ACAP further complained about many EDE entities’ “pay-to-play” business models, which can lead to the exclusive or preferential display of plans that can pay the fees, denying consumers the ability to fully assess and compare available plan options. Some commenters called on CMS to prohibit EDE platforms from charging insurers to participate, and to preserve states’ ability to assess user fees.
BCBSA noted that Georgia’s SBM-EDE model has led to consumer frustration and confusion. Many Georgia consumers do not know the EDE vendor through which they enrolled, and call their insurer first when there is a problem. Because the insurer may also not know which vendor was used, enrollees “can be directed in circles between their [insurer], state insurance regulator, and enrollment partner.” NABIP shared similar concerns, observing that a “centralized [Marketplace] pathway helps ensure a consistent enrollment experience and provides a reliable support channel when consumers encounter application or eligibility issues.”
Several commenters in our sample raised concerns about broker fraud and program integrity, noting that consumers using EDE vendors to enroll were significantly more likely to have “APTC discrepancies” due to missing or incorrect data issues. At a minimum, they called for implementation of the SBM-EDE model to be delayed until current EDE platforms have resolved outstanding program integrity concerns.
Non-network plans
CMS proposes to enable plans that do not have a provider network to participate in the Marketplaces. The agency provides a proposed regulatory framework for assessing whether such plans meet the Marketplace certification criteria.
In our sample, only the Sidecar Health Insurance Company supported the inclusion of non-network plans in the ACA Marketplaces. The insurer currently operates non-network plans in the employer and off-Marketplace individual markets, and argued that allowing non-network plans would expand consumer choice and promote competition. However, Sidecar urged CMS to delay implementation of its proposal to plan year 2028, noting that the company would not be able to meet the fast-approaching deadlines for 2027 Marketplace plan certification.
The other organizations in our sample raised numerous concerns about the proposal. Several pointed out that the regulatory framework for certifying non-network plans lacked sufficient information for stakeholders to meaningfully comment on it. AHIP for example called for more detail on “how non-network plans would mathematically demonstrate network adequacy, provide credible provider reference price data, establish formularies, maintain claims review and appeals processes, appropriately apply cost-sharing to out-of-pocket limits, and calculate [actuarial value] using in-network benefits.” They and others further asked for CMS to clarify that all federal consumer protections, such as the ACA’s preventive services benefit and cap on annual out-of-pocket costs, the No Surprises Act, continuity of care, and the Mental Health Parity and Addiction Equity Act (MHPAEA) apply equally to networked and non-network Marketplace plans.
Several also raised consumer protection concerns, noting that non-network plans demand high degrees of medical and insurance literacy on the part of Marketplace enrollees and would be likely to leave consumers with unexpected balance bills. NABIP observed that, in its members’ experience, many providers have refused to serve non-network plan enrollees, resulting in “billing disputes, scheduling barriers, and continuity-of-care disruptions that ultimately fall on the patient.” The association goes on to note that such challenges would be even greater for consumers in the individual market, where they lack the support structures of employer-sponsored insurance. BCBSA reminded CMS that many high-cost health care services are not shoppable. “In these situations, consumers cannot reasonably be expected to shop for care, and the absence of a provider network leaves them exposed to significant and unpredictable financial liability.” If CMS moves ahead with the proposal, most insurers in our sample urged the agency to ensure that consumers can clearly distinguish between network and non-network plans on HealthCare.gov and are given clear and comprehensive pre-enrollment disclosures about how such plans differ from traditional network-based plans, including information about the risk of balance billing.
Commenters also expressed concerns that non-network plans would de-stabilize the Marketplaces and be allowed to operate on an unlevel playing field. CMS’ proposed regulatory framework would permit non-network plans to self-attest to network sufficiency and “enter the market based on [insurer] representations that cannot be independently verified or meaningfully evaluated by regulators.” ACAP expressed the belief that non-network plans would not compete fairly with network-based plans, with “the end-result of bifurcating the individual market” between healthy and unhealthy enrollees. BCBSA further noted that non-network plans present actuarial and pricing characteristics that “differ materially from traditional network-based [plans],” raising the risk of rate inadequacy, insolvencies, and premature product withdrawals. Similarly, Elevance observed that the current ACA regulatory framework pre-supposes that plans are network based; the inclusion of non-network plans “warrant careful evaluation and regulatory clarity…to avoid unintended market disruption.”
Catastrophic plans
The proposed rule includes policies that would expand the types of people eligible for catastrophic plans, permit catastrophic plans to be marketed as multi-year products, and allow catastrophic and bronze-level plans to exceed the statutorily mandated annual maximum out-of-pocket (MOOP) cost-sharing liability for enrollees. CMS also asks for comment on whether catastrophic plans should continue to be rated in a separate risk pool from the metal level plans.
The stakeholders in our sample were generally opposed to CMS’ proposals with respect to catastrophic plans. There was little support for expanding eligibility for such plans, with ACAP expressing concern that consumers would be “targeted by aggressive marketing and sign up for catastrophic coverage….ultimately meaning consumers may not be able to access needed care.” NABIP had a slightly more nuanced view, expressing support for expanding eligibility to people under 100 percent of the federal poverty level (FPL) who are not eligible for premium tax credits, but opposing the extension of eligibility to people between 250 and 400 percent of the FPL who are eligible for premium tax credits.
The insurers in our sample also shared considerable concerns about multi-year catastrophic plans. AHIP urged CMS to engage in a more thoughtful and robust process to develop a regulatory framework for such plans, noting that currently there is too little data to evaluate the pricing or market impact of multi-year catastrophic plans: “[S]everal fundamental policy questions must be answered before [CMS] can move forward….” Centene similarly noted that “[m]ulti-year catastrophic plans would be incredibly difficult to price responsibly, given uncertainty around medical trend, utilization, regulatory requirements, and risk adjustment over extended periods.” BCBSA pointed to the long-term care (LTC) insurance market as an instructive case study of the risks associated with multi-year insurance products: “Insurers attempted to price multi-year LTC contracts in the 1990s but due to challenges projecting medical cost trends, utilization patterns and lapse rates over extended timeframes, they faced reserve shortfalls, premium increases of 50–300%, insolvencies, and a near-collapse of the private LTC market.” Elevance called on CMS to evaluate the effect of recent federal policy changes such as the expiration of premium tax credits and enrollment shifts before “introducing additional structural changes to a segment of the market that remains relatively small but potentially volatile.”
ACAP expressed concerns about the adequacy of consumer protections under CMS’ proposal, noting: “if a consumer enrolls in multi-year coverage with a front-loaded deductible, but [insurers] are allowed to discontinue the product or exit the market, consumers would lose the so-called ‘benefit’ of more affordable care in future years—potentially without any recourse.” BCBSA similarly called on CMS, if it finalizes the proposal, to require “robust consumer disclosures defining the differences and limitations of these arrangements.”
In our sample, only NABIP expressed support for the concept of multi-year catastrophic plans as a new option for consumers.
The insurer stakeholders in our sample had mixed reviews of CMS’ proposal to increase the MOOP for catastrophic and bronze plans. Most were generally opposed to doing so for catastrophic plans, or called for delay. But they were more supportive of lifting the MOOP for bronze-level plans. BCBSA for example noted that the tension between the actuarial value requirements and the statutorily set MOOP that exists for bronze plans does not exist for catastrophic plans. AHIP called for CMS to delay lifting the MOOP for catastrophic plans until additional data about enrollment in these plans are available, but both insurer trade associations supported greater flexibility for cost-sharing parameters on bronze plans.
Oscar and NABIP, on the other hand, had concerns about changing the MOOP for both bronze and catastrophic plans, with NABIP flagging the financial risks for consumers associated with higher cost-sharing, and Oscar worried that some insurers could “push these bounds in unforeseen ways…driving adverse selection across similar plan designs.” Oscar further suggested that if CMS finalized its proposal, it rename bronze plans with higher MOOPs to make them distinguishable, such as “Bronze Light.”
Insurers were mixed on whether catastrophic plans should maintain their own risk pool. BCBSA and Oscar, for example urged CMS to keep the risk pools for catastrophic and metal level plans separate, noting the need for time to assess the long-term implications of recent federal-level policy changes. ACAP in its comment flagged risks associated with both options, noting that keeping catastrophic plans in a separate risk pool while expanding eligibility could “pull healthy consumers out of the main risk pool,” while placing catastrophic plans in the same risk pool as metal level plans could decrease statewide premiums, destabilize the individual market, and have the perhaps unintended impact of increasing premiums for catastrophic plans.
New reporting on CSR costs
In 2025, CMS asked insurers that adjust premium rates to account for unreimbursed CSRs to provide a detailed accounting of how they’ve done so. The proposed rule would codify and continue that policy. The stakeholders in our sample shared significant concerns about the operational and financial burdens associated with such reporting requirements and urged, at a minimum, a delay in implementation. BCBSA reported: “Our member Plans report that standing up a retrospective CSR reconciliation process is not simply a matter of turning on an existing IT system. For many issuers, retrospective reconciliation…requires handling appeals, retroactive adjustments, and manual corrections.” AHIP also raised the prospect that the reporting could expose “confidential and proprietary rate setting information” to the public. Elevance and others requested that CMS grant a “safe harbor” for insurers attempting to comply in good faith with the reporting requirements, while NABIP suggested that “overly prescriptive reporting requirements” could discourage some insurers from participating in the Marketplaces.
Request for comment on adjustments to the medical loss ratio standard
CMS solicits public comment on whether it should adjust the ACA’s medical loss ratio (MLR) standards, and if so, the best process for doing so. The agency suggests that it is considering changes to the MLR, even in the absence of a state request to do so. The insurers in our sample sought to dissuade CMS from pursuing changes to the current approach to determining MLR standards. Most noted that states, not the federal government, are in the best position to assess the stability of their insurance markets. The insurers also asserted that the current process and data requirements for a state to request a MLR adjustment are adequate. NABIP took a slightly different view, supporting federal authority to adjust the MLR standard, but noting that any changes should be governed by “objective, data-driven triggers, such as sustained [insurer] exits, measurable declines in competition, persistent underwriting losses, or other indicators of structural market stress.” The association also encouraged CMS to reassess the MLR framework and its application to an increasingly vertically integrated health care system and the numerous and complex financial relationships between insurers and third-parties, such as pharmacy benefit managers, provider groups, revenue cycle managers, third party administrators, and more.
Note on Our Methodology
This blog is intended to provide a summary of comments submitted by insurer and broker organizations. This is not intended to be a comprehensive review of all comments on every provision in the proposed rule, nor does it capture every component of the reviewed comments. To view more stakeholder comments, please visit https://www.regulations.gov/document/CMS-2026-0496-0002/comment.
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