Proposed Rule Could Undermine ACA Coverage

Last week, the Medicare Rights Center submitted comments to the Centers for Medicare & Medicaid Services (CMS) on proposed changes to Affordable Care Act (ACA) plans.

CMS typically updates ACA policies each year. For 2027, the proposals include several that could limit access to affordable coverage, increase administrative and choice barriers, and harm consumers. As outlined below, our comments focused on these provisions, drawing upon our experience helping people shop for and navigate coverage.

Rolling Back Plan Standardization

Within the Federally Facilitated Marketplace (FFM), CMS is proposing to eliminate standardized plan requirements and lift restrictions on the number of non-standardized plans insurers can offer. Although states could impose their own limits, such actions are not guaranteed, and at best would create a patchwork system.

We oppose proposals to eliminate standardized plan requirements.

We oppose these proposals and urged CMS to withdraw them. In our experience with similar changes in Medicare Advantage (MA), people are unable to effectively evaluate their coverage options and select the best plan for their unique circumstances when faced with too many choices. Remaking the federal Marketplace in this image would replicate these problems.

Specifically, the elimination of meaningful difference and uniformity requirements within MA has contributed to seemingly endless numbers of MA plans that can vary on everything from costs to coverage, sometimes in subtle but important ways. For most beneficiaries, this makes close analysis both critical and unattainable.

Research indicates comparing each plan deviation is a challenging, intimidating, and time-consuming task that few people with Medicare perform.

Indeed, research indicates comparing each plan deviation, year after year, is a challenging, intimidating, and time-consuming task that few people with Medicare perform. Enrollees who arguably have the most at stake—those who are older, have lower incomes, are living with cognitive impairments, or have serious health needs—are also the least likely to review and change their coverage. Consumers who do engage may suffer decision fatigue and make no choice at all.

This inertia, and any suboptimal enrollments, can have serious consequences. The penalty for a poor fit between what a plan offers and what an individual needs may include delays in care, higher out-of-pocket costs, and barriers to preferred providers.

The Marketplace must not follow MA’s lead. Although MA choice is overly burdensome and complex, CMS has taken a different approach with the Marketplace by adopting policies that modernize systems and empower consumers. In so doing, CMS has demonstrated that used effectively, plan standardization and proliferation guardrails can heighten transparency, improve decision-making, and streamline plan selection.

CMS has demonstrated that plan standardization and proliferation guardrails can heighten transparency, improve decision-making, and streamline plan selection.

Diluting Network Adequacy

CMS is also proposing to water down network adequacy oversight and requirements, in part by loosening requirements that Marketplace plans contract with a minimum number of providers and by boosting access to plans that do not have contracted provider networks and instead set their own payment rates, leaving enrollees on the hook for charges above that amount.

Medicare provides a good illustration of the pitfalls of CMS’s proposed approach.

Here too, Medicare provides a good illustration of the pitfalls of CMS’s proposed approach. Most providers participate in Medicare and adhere to its payment rates. But many psychiatrists either formally opt-out of Medicare or do not regularly accept new Medicare patients. A beneficiary who cannot find a participating psychiatrist must either forgo needed behavioral health care or pay for it on their own.

For example, a recent caller to Medicare Rights Center’s National Helpline could not find a psychiatrist in her rural county and had to go without care for several months. This is a situation we see far too often. While such delays are always problematic, they can pose a particular hardship for those with behavioral health conditions.

CMS’s proposal would create this risk on an even larger scale. Non-network plan enrollees could find themselves unable to rely on their coverage, unable to predict their health care expenses, and unable to access their providers.

Non-network plan enrollees could find themselves unable to rely on their coverage.

Conclusion

As proposed, the 2027 ACA rule would remove critical consumer protections that promote access to care. CMS acknowledges its policy and operational changes would jeopardize coverage, as the rule is projected to cut enrollment by 1.2 to 2 million people. Notably, these losses are in addition to those stemming from the expired tax credits. We ask that CMS recalibrate its approach to do more to ease enrollment and other burdens, not less. Those shopping for and navigating ACA coverage need better, more affordable, and higher quality choices.