New Final Rule Pushes Marketplace Enrollees Toward Lower-Quality, More Expensive Coverage

A new Affordable Care Act (ACA) marketplace rule finalized by the Centers for Medicare & Medicaid Services adds to the burdens of millions of people in the United States who are already struggling to afford their health care costs. The rule changes advance deeply unpopular policies that weaken financial protections for marketplace enrollees, expose them to thousands of dollars more in deductibles and other out-of-pocket costs, and subject them to untested plan designs that could increase insurers’ profits at enrollees’ expense.

The new rule gives insurers more leeway to offer marketplace plans with higher out-of-pocket costs starting in 2027. The changes come on the heels of significant premium increases in the marketplaces, after congressional Republicans and the Trump Administration failed to extend premium tax credit enhancements at the end of 2025 and enacted large Medicaid and marketplace cuts in last July’s reconciliation bill. As a result, marketplace enrollees are currently struggling to afford coverage and care. Some are forgoing cost-sharing reductions that make care in benchmark silver plans more affordable and instead opting for lower-premium, less generous plans; others are even leaving the marketplace altogether and may lose coverage that helps them afford the health care they need.

This new rule advances the Trump Administration and congressional Republicans’ agenda to further undermine quality, affordable marketplace coverage and weaken financial protections for enrollees. In addition to generating increased administrative burdens and complexity, the rule permits insurers to offer plans that are less generous and provide fewer consumer protections than previously available plans. Recent data show that marketplace enrollees are facing higher costs for lower-quality coverage this year. The rule will make coverage even more expensive for many people, including by:

• Promoting catastrophic plans with higher deductibles and other costs. These plans have lower premiums, but they leave people on the hook for the full cost of their health care until they reach the maximum out-of-pocket amount allowed under the ACA ($10,600 for an individual and $21,200 for a family in 2026). The rule codifies 2025 guidance allowing people age 30 and older to qualify for a hardship exemption and enroll in a catastrophic plan if they become ineligible for premium tax credits (PTCs) or cost-sharing reductions.

  Starting in 2028, the rule also increases the amount people have to pay out of pocket before catastrophic coverage kicks in by 30 percent. This change could be especially harmful to people with chronic conditions, who are more likely to delay or forgo recommended medical care and have lower medication adherence when enrolled in high-deductible plans.

• Increasing out-of-pocket limits for bronze plans. A record 40 percent of marketplace enrollees are relying on bronze plans this year after the expiration of PTC enhancements put plans with higher premiums out of financial reach. But the rule increases the maximum out-of-pocket for bronze plans by 30 percent in 2027, to $15,600 for an individual and $31,200 for a family. For perspective, $15,600 is about a third of median personal income, and roughly the entire income of a person at the federal poverty level. People enrolled in bronze plans could face thousands of dollars more in out-of-pocket costs next year.
• Inviting insurers to offer plans that last multiple years. Starting in 2027, the rule also allows insurers to offer multi-year catastrophic plans with terms of up to ten years, rather than the traditional one-year term — a proposal that raised concerns among many experts and stakeholders. This change will make plan selection more confusing and expose people to very high out-of-pocket costs, while doing little to improve the affordability or value of coverage.

• Allowing insurers to offer plans that lack a network of physicians, hospitals, and other providers. The rule allows insurers to offer so-called non-network plans starting in 2027 or 2028, depending on the state. These plans set specific benefit amounts for covered services but do not have a network of providers that have agreed to accept the rates set by the plan. The rule requires insurers to show these plans will provide a sufficient choice of providers, but it does not specify how non-network plans would operate and meet ACA standards for marketplace plans. Insurers could create informal agreements with providers to meet the sufficient choice standard, but the rule does not require them to obtain formal commitments.

  There is no guarantee that people would be able to determine whether their providers accept the benefit amounts when selecting a plan. Even if providers agree to the plan’s payment rates, they can pull out of these agreements without warning, leaving enrollees saddled with any health care costs that exceed what the plan will pay.

  In addition, the presence of non-network plans may shrink the amount of financial help available to all marketplace enrollees, since these plans are likely to have lower premiums, which could drag down the premium of the second-lowest-cost silver plan (that is used to set the value of the PTC).

The rule weakens consumer protections and pushes people towards lower-quality plans that put them at risk of higher out-of-pocket costs. At a time when many marketplace enrollees are already struggling with rising health care costs, this new rule will make it even harder for people to afford the health coverage they need.