By Jason Levitis, Christen Linke Younger, Sabrina Corlette, Ellen Montz, and Claire O’Brien*
The medical health insurance provisions of the reconciliation invoice handed by the U.S. Home of Representatives would remove a lot of the pliability granted to states over the operations of State-Based mostly Marketplaces (SBMs), impose pricey new mandates, and scale back their income base. These modifications might undermine states’ worth proposition for establishing or sustaining an SBM. On the similar time, the invoice would infringe on states’ long-standing primacy over the regulation of personal medical health insurance by imposing arbitrary new federal guidelines.
The Invoice Eliminates SBM Flexibility and Imposes New Operational Mandates
The Reasonably priced Care Act (ACA) offers SBMs flexibility over quite a few operational choices. For instance, the rules governing Market eligibility determinations allow SBMs to conduct annual redeterminations utilizing both the procedures offered within the CMS rule, various procedures specified by CMS for the relevant plan 12 months, or various procedures proposed by the SBM and authorised by CMS. The ACA additionally delegates to SBMs authority to ascertain particular enrollment durations (SEPs), depend on their very own alternate model of the one streamlined utility, and in any other case tailor the SBM to the wants of the state. SBMs have used this flexibility to implement progressive measures to attenuate burdens on eligible enrollees, usually with the assistance of digital knowledge sources and different IT options. Doing so has allowed them to increase enrollment and maintain premiums low with out the prevalence of agent and dealer fraud skilled on the federal Market (known as the Federally Facilitated Market, or FFM).
The reconciliation invoice would remove this long-standing flexibility throughout a variety of SBM design points, whereas additionally imposing a number of new and dear operational mandates:
- Eliminates state flexibility to find out open enrollment durations. Present regulation permits SBMs to prolong their open enrollment durations previous the federal open enrollment finish date of January 15. The invoice would require all Marketplaces to shorten their open enrollment durations to only 44 days, from November 1 to December 15. Many SBMs have maintained constant open enrollment interval begin and finish dates during the last decade that insurers and customers have come to depend on; requiring SBMs to alter these dates might undermine native market stability.
- Eliminates state authority to supply a standard particular enrollment interval. Present regulation supplies SBMs with discretion to ascertain particular enrollment durations (SEPs), which permit enrollment outdoors the year-end open enrollment interval. Utilizing this authority, each the federal Market and all however two SBMs present a SEP for low-income people. The invoice would prohibit this SEP and others primarily based on earnings.
- Requires states to impose further paperwork burdens on customers and confirm eligibility manually. Present regulation offers SBMs broad discretion over when, how, and in what format they request further data to confirm eligibility for Market protection, for a SEP, or to obtain advance premium tax credit (APTC). For instance, SBMs can usually depend on candidates’ attestations as to their eligibility for SEPs moderately than requiring them to manually submit paperwork, equivalent to documentation that they’ve misplaced earlier protection. The invoice would require SBMs to confirm SEP eligibility with paperwork from candidates for at the least 75 p.c of SEP enrollments. The invoice would additionally require Marketplaces to demand further paperwork from tens of millions of further candidates when the IRS doesn’t return tax knowledge or when tax knowledge signifies very low earnings.
- Eliminates state flexibility to shift customers by default into plans that make the most of obtainable subsidies. For people who’re eligible for cost-sharing reductions (CSRs) however enrolled in a bronze plan, present guidelines allow SBMs to re-enroll them by default in a silver plan for the next 12 months in order that they will obtain CSRs, so long as the silver plan is comparable and no extra pricey. A number of states have taken benefit of this flexibility to make sure eligible customers profit from the ACA’s cost-sharing protections and scale back monetary obstacles to vital well being care providers. The invoice eliminates this flexibility for SBMs.
- Eliminates passive re-enrollment and state flexibility to depend on trusted knowledge sources. Present guidelines present for SBMs to routinely re-enroll present enrollees who don’t return to the Market to actively re-enroll, with APTCs adjusted primarily based on digital knowledge sources. SBMs at the moment have flexibility over the information sources used to make these determinations, which can embody not simply federal tax knowledge but in addition state tax knowledge and state wage filings. The invoice would prohibit SBMs from performing re-enrollment with APTC with out new data offered by the buyer, successfully eliminating automated re-enrollment. This runs counter to straightforward re-enrollment practices for each different type of insurance coverage, together with employer-based insurance coverage. We’re conscious of no precedent for the federal authorities prohibiting automated reenrollment for a line of insurance coverage. SBMs have disproportionately leveraged auto-renewal to create secure and aggressive markets, with a median of 73% auto-renewal fee for returning clients in comparison with 46% within the FFM. As well as, for one 12 months earlier than the prohibition on passive re-enrollment takes impact, a separate part of the invoice would prohibit automated re-enrollment with a zero-dollar internet premium, by requiring SBMs to cut back APTC in such circumstances to cost a $5 internet premium.
- Prohibits SBMs from offering APTC after asking customers for added documentation. Present statute directs Marketplaces to present APTC once they ask for added paperwork to confirm sure eligibility standards, if they’ve decided that the person is in any other case eligible. The invoice would remove this “provisional eligibility,” successfully requiring a ready interval of a number of months for a lot of candidates. Once more, we’re conscious of no precedent for a federal requirement for a months-long ready interval for a line of business insurance coverage.
- Requires states to ascertain a brand new “pre-enrollment verification” system operating from August by means of October annually. Present guidelines allow SBMs to depend on related eligibility and enrollment procedures year-round for energetic re-enrollment. Eligibility determinations are usually made rapidly, so protection can start a month or much less after the applying is submitted. The invoice would require SBMs to face up a brand new and separate equipment for “pre-enrollment verification,” underneath which customers might submit eligibility data for the next 12 months beginning in August, however protection would nonetheless not start till January. This new system must be in place by August 1, 2027.
Decreasing flexibility in these methods would make establishing or sustaining an SBM much less engaging for states. Flexibility is a key motive cited for curiosity amongst states which have just lately adopted or thought of transitions, together with Georgia, Illinois, Texas, Oklahoma, and Oregon, and a key profit cited by current SBMs.
It is usually notable {that a} major justification supplied for the invoice’s elimination of SBM flexibility is to cut back “fraud.”a Actually there is no such thing as a proof that the agent and dealer fraud skilled by the Federal Market is an issue for SBMs. Eradicating their means to take care of present finest practices will lead to tens of millions of eligible people dropping protection. The brand new necessities serve solely to pressure states to stick to one-size-fits-all federal requirements that stop SBMs from responding to native market circumstances and offering an optimum buyer expertise.
The Invoice Would Impose New One-Time and Ongoing Prices on SBMs
The brand new mandates described above create intensive and dear new work for SBMs. There could be fast implementation work to alter programs, retrain workers, and educate customers and companions about impending modifications, in addition to ongoing work to hold out extra burdensome enrollment procedures with much less means to depend on digital knowledge. Switching from automated checks towards third-party knowledge sources to handbook processes will increase prices and burdens for each SBMs and customers and reduces the effectivity of the system. These prices will must be coated by larger person charges, which in flip will increase premiums for all customers within the particular person market, no matter whether or not they buy on or off the Market. These value embody:
- Rebuilding IT structure. The a number of modifications described above would require SBMs to rebuild many features of each consumer-facing and back-end eligibility programs. CMS estimated an IT value of $158.3 million for implementing the Market rule, which the invoice would codify.b That doesn’t embody eliminating passive reenrollment and provisional eligibility and the creation of latest programs for pre-enrollment verification starting in August, that are three of essentially the most far-reaching modifications within the invoice. Some provisions make conflicting modifications that will require rebuilding the identical structure twice. For instance, SBMs would want to alter their programs to impose a $5 premium for automated re-enrollees beginning within the fall of 2026. After which they would want to alter their programs once more to remove automated re-enrollment beginning within the fall of 2027.
- Retraining name middle workers, caseworkers, and assisters. SBMs would want to develop and supply new coaching supplies for consumer-facing workers and companions, together with name middle operators, caseworkers, Navigators, brokers and brokers, and authorized utility counselors.
- Dealing with further buyer interactions. Eliminating automated re-enrollment–which accounted for 10.8 million enrollments in 2025–would imply that each applicant would want to work together with the Market annually. The pre-enrollment verification system may even create tens of millions of further buyer interactions. And these interactions won’t substitute these throughout the open enrollment interval. People will nonetheless want to return in then to enroll and select a plan. And there’ll nonetheless be modifications in circumstances after August, which would require reporting these modifications and resolving any additional inconsistencies that come up. Consequently, SBMs received’t simply do extra verifications, they may do verification a number of occasions for a similar shopper.
- Processing further paperwork. The brand new paperwork required from candidates underneath the invoice would additionally necessitate an amazing new effort from SBMs to course of the paperwork. For instance, CMS estimated that the brand new earnings verification guidelines would require 2.7 million candidates to submit further paperwork, all of which might must be processed. The SEP verification requirement would imply 473,000 extra candidates offering paperwork to confirm their eligibility for an enrollment alternative. SBMs would want to rent and practice new consumer-facing assist workers and/or contractors to manually evaluate and make sure eligibility verification paperwork submitted by customers. On high of the prices of IT modifications, CMS estimated that SBMs might want to spend $60.3 million yearly or $603.4 million over 10 years to implement the modifications within the rule alone.
- Extra buyer assist workers to handle questions and opposed determinations. The extra interactions and paperwork necessities would result in many extra customers needing assist to resolve questions. The elimination of provisional eligibility would increase the stakes for resolving eligibility points rapidly, possible growing the quantity and urgency of those calls.
- Maintaining extra workers and contractors for extra of the 12 months. At present Market can cut back their operations outdoors of the open enrollment interval. However a number of components of the invoice will enhance prices at different occasions of the 12 months, together with pre-enrollment verification starting in August and extra eligibility verification for SEPs and APTC eligibility year-round.
- Further communications necessities. SBMs might want to spend money on new outreach and communications efforts to teach customers and companions about their new obligations underneath the invoice and the shortened time durations that customers must meet these obligations.
The Invoice Would Scale back SBMs’ Income Base
The Reasonably priced Care Act requires the Marketplaces to be financially self-sustaining. Most SBMs depend on premium assessments or per member person charges to generate the income to fund their operations. The reconciliation invoice would scale back Market enrollment by tens of millions of individuals, thus lowering SBM income. To be financially sustainable, SBMs might want to enhance their person charges. This can lead to a rise in premiums, which might, in flip, result in additional enrollment losses.
The Invoice Might Alter States’ Calculus about Establishing (or Sustaining) an SBM
As mentioned above, the invoice would cut back the pliability afforded to SBMs, enhance their working prices, and scale back their income. Taken collectively, these modifications could undermine the worth proposition of states transitioning to or sustaining an SBM. Over the course of the final decade, the variety of states with an SBM has grown from 15 within the first 12 months of implementation to 20 states in the present day (Illinois and Oregon will make it 22 in 2026 and Oklahoma’s legislature licensed that state to turn into the twenty third SBM in a invoice enacted in Might 2025). State lawmakers have proven growing curiosity in transitioning to an SBM to make the most of the flexibilities that allow them to tailor their Market to satisfy the wants of state residents. Nonetheless, underneath H.R. 1 states will lose that flexibility and are confronted with larger prices and a smaller enrollment base from which to finance operations. This makes it much less possible that states will select to transition to a SBM sooner or later and will lead to some present SBMs changing into unsustainable, requiring the federal authorities to take over their operations. As well as, the invoice’s implementation timeline would stop a state now not prepared to run an SBM from transitioning to the FFM earlier than being required to implement modifications.
The Invoice Would Infringe on State Regulation of the Particular person Well being Insurance coverage Market
For many years, states have had major authority for regulating medical health insurance markets. Some federal requirements had been codified within the Public Well being Service Act (PHSA) by the Well being Insurance coverage Portability and Accountability Act of 1996 (HIPAA) and the ACA. Nonetheless, the PHSA necessities deal with solely a comparatively small variety of points and customarily defer to states on particular implementation selections and on enforcement. The reconciliation invoice incorporates a number of provisions that infringe on this long-settled vesting of authority, together with modifications affecting plans outdoors the Well being Insurance coverage Marketplaces.
- Infringes on state authority to outline important well being advantages. At present, every state has authority to ascertain the important well being advantages (EHB) bundle, which is relevant to all personal medical health insurance. States have authority to designate as EHBs any service that’s included inside 10 broad classes enumerated within the ACA. The invoice supplies that EHBs could not embody particular providers associated to “gender transition”–even these providers that fall squarely throughout the ACA’s EHB definitions. This may be the primary time states are prohibited from together with particular providers as EHBs.
- Eliminates state flexibility to allow insurers to supply reduction for non-payments of de minimis premiums. Present guidelines give state insurance coverage regulators flexibility to allow insurers to maintain enrollees coated even once they owe small past-due premium balances. The invoice would cut back states’ authority to supply such flexibility.
- Denies cost-sharing subsidies funds to insurers that present sure abortion providers–however in a means that rewards states with abortion mandates. The invoice supplies that issuers that present sure abortion providers could not obtain reimbursement for the ACA’s CSRs. As CBO famous in a current evaluation of the invoice’s protection results, this may unintuitively enhance PTC funds in states that require Market plans to cowl abortion, and better PTC would enhance the person market danger pool general in such states. It could additionally lead to much less abortion protection in Market plans in states that allow however don’t require abortion protection, since insurers that cowl abortion would want to extend premiums to account for the dearth of CSR funds, which might possible not be a viable possibility. However these complicated repercussions, this abortion language is clearly an effort to infringe on state coverage selections relating to the advantages offered by personal medical health insurance.
- Limits enrollment alternatives market-wide. As famous above, the invoice limits state flexibility to ascertain open and particular enrollment durations of their SBMs. Crucially, this additionally impacts state regulation of well being plans of their complete particular person insurance coverage market, as a result of plans bought by means of the Market are a part of a single danger pool with non-Market plans, which suggests it is very important set up the identical enrollment home windows on and off Market. Thus, state insurance coverage regulators are constrained of their means to ascertain enrollment home windows that meet state wants.
- Loosens actuarial worth guidelines market-wide: The invoice modifies requirements for the actuarial worth of all particular person market well being plans to permit much less beneficiant plans, relevant on and off Market pursuant to ACA Part 1311 and PHS Act Part 2707. States might restrict the attain of this provision by defining standardized profit packages. However in lots of states such guidelines don’t apply outdoors the Market, so much less beneficiant plans will turn into obtainable in these market segments.
As well as, the invoice would make an extra change to the PHSA. Particularly, it will exempt insurers from the assured availability requirement in circumstances of past-due premiums, until state regulation specified in any other case.
* Jason Levitis is a Senior Fellow, and Claire O’Brien a Analysis Affiliate, within the City Institute’s Well being Coverage Division; Christen Linke Younger is a Visiting Fellow on the Brookings’ Heart on Well being Coverage; Sabrina Corlette is a analysis professor and co-director of the Heart on Well being Insurance coverage Reforms (CHIR) at Georgetown College; Ellen Montz is a Managing Director at Manatt Well being. The views expressed on this piece are these of the authors and don’t essentially characterize these of their organizations or their boards or funders.
a Actually, these Market proposals within the invoice fall underneath headers entitled “Addressing waste, fraud, and abuse within the ACA Exchanges” and “Stopping Fraud, Waste, and Abuse.”
b CMS didn’t embody an estimate for prices to SBMs underneath the prohibition of SEPs for low-income people as a result of it incorrectly claims that no SBMs at the moment have a SEP of this type. The $158 million value contains $7 million for this provision, which is calculated by taking the estimate for the price of these IT modifications to the FFM ($390,000) and multiplying it by the variety of SBMs with this SEP (18).
