Higher Deductibles, More Barriers, Fewer Protections: How the New Marketplace Rule Would Further Erode Access to Affordable, Quality Health Coverage

People who buy coverage individually through the marketplace will be negatively impacted by new regulations proposed by the Trump Administration, which would promote plans with higher deductibles and cost-sharing and plans with no networks, and otherwise put in place more barriers to benefits and coverage.

Every year, the Centers for Medicare and Medicaid Services (CMS) release the Notice on Benefit and Payment Parameters (often called the “payment rule”) which outlines how the Affordable Care Act marketplaces will operate the following year. This year’s proposed payment rule includes significant changes that, if finalized, would allow plans to offer worse coverage with weaker provider networks and fewer consumer protections than what is currently required under federal rules. Below is a summary of the key provisions included in the rule that would negatively impact consumers that buy coverage as individuals or families, rather than those who get coverage through an employer or public program. CMS proposes to:

• Expand eligibility for “catastrophic” plans and increase deductibles and cost-sharing for consumers: Catastrophic plans are exactly what they sound like: a health plan that may protect you in a worst-case scenario but offers very little help with everyday medical needs. Even in an emergency, you would face a deductible as high as $15,600 for an individual, or $27,600 for a family. Currently, catastrophic plans are only available to young adults under 30, or people who do not qualify for premium tax credits. Under this rule, CMS proposes to do three things: 1) allow people who are below poverty (i.e. less than $32,000 for a family of four) or above 250% of the federal poverty level (about $75,000 for a family of four) to enroll in these plans if they do not qualify for premium tax credits or cost sharing reductions; 2) raise the out-of-pocket costs that people might experience in these plans, and 3) establish a new form of “multi-year” catastrophic plans. While the Trump administration argues these efforts are creating new pathways for families to get health care coverage, these options are simply unaffordable and often unwise for low and moderate-income families. The bottom line: Because Congress allowed the enhanced premium tax credit to expire and has so far failed to rein in the root drivers of rising health insurance premiums (namely drugs and hospital prices), the cost of comprehensive coverage is becoming even more unaffordable — but the solution isn’t to have people pay more and get less, as with junk and catastrophic plans with sky-high deductibles.
• Restrict eligibility for lawfully present immigrants: Implementing H.R. 1, the proposed rule would limit premium tax credits to “eligible noncitizens” instead of a broader category of lawfully present immigrants that have historically been eligible. The proposed rule also denies tax credits to people below the federal poverty level who are ineligible for Medicaid due to current federal law that already restricts access to Medicaid services based on immigration status. The proposed rule would also deny federal payment for this population to states with Basic Health Programs. If finalized, this change would threaten access to health care for more than one million lawfully present immigrants who rely on marketplace coverage and another 10,000 who rely on coverage through a Basic Health Plan (available in the District of Columbia, Minnesota, New York and Oregon).
• Weaken access to care by reducing provider network protections: The rule would allow plans that provide no guarantee that any health provider take its patients. Specifically, these plans could operate without any provider networks and reduce requirements that plans contract with essential community providers like community health centers and Ryan White HIV/AIDs providers. Many consumers and patients could buy health coverage that is like a coupon no one will redeem, where no doctors or specialists are contracted to accept the plan’s payment rates in your area, essentially leaving consumers with limited or no access to health care.
• Make it harder to maintain and improve benefit standards: Under federal law, all marketplace plans must cover a core set of services known as “essential health benefits” (EHBs), so consumers know they are purchasing meaningful coverage. Some states have expanded beyond the federal minimum to cover additional services such as opioid use disorder treatment, improved maternity care, and gender-affirming care. Other states are in the process of adding routine adult dental care to their EHBs. If the proposed rule takes effect,
• Increase enrollment barriers by requiring more paperwork: The proposed rule would add new income verification and enrollment requirements, creating more administrative hurdles that can result in eligible people losing coverage.
• Invite fraud by expanding the use of privatized enrollment platforms: The rule would allow state-based marketplaces to fully outsource enrollment to private web brokers through “enhanced direct enrollment” (EDE) platforms. EDE platforms have been linked to unauthorized plan switching and fraudulent enrollments, and in 2024 alone, 850 agents and brokers were suspended for this behavior. While not all EDE platforms engage in misconduct, allowing states to fully outsource enrollment increases the risk that consumers — especially those with low health insurance literacy or who are non-English speakers — could be steered into higher cost plans that fail to offer comprehensive coverage.
• Make plan selection more confusing by ending standardized plans in HealthCare.gov: Currently, the marketplace is organized so that consumers can compare plans at the same metal level which have the same deductible and cost-sharing structure, making it easy for consumers to shop for a health plan that best meets their needs. Removing this standardization would undermine the ability for consumer to effectively shop for a health plan by making it more difficult and confusing for consumers to sort through and compare plans with vastly different deductibles, co-pays, and out-of-pocket limits.
• Change oversight of “silver loading”: Since 2017, insurers have used a practice known as “silver loading” to account for the cost of cost-sharing reductions (CSRs) which Congress stopped directly funding during the failed attempts to repeal the ACA. This approach has generally helped consumers who qualify for premium tax credits by increasing subsidies and keeping other metal-level plans more affordable. The proposed rule does not eliminate silver-loading, but it would require insurers to report significantly more data and standardize reporting on how CSR costs are calculated. If insurers adjust their pricing practices in response, bronze and gold level plans could become more expensive making it more difficult for consumers and patients to access the care they need at a price they can afford.

The rule also appropriately proposes new consumer protection standards that would tighten broker conduct, requiring the use of HHS-approved consent forms, prohibiting cash payments or rebates to enrollees, and cracking down on misleading marketing. While these changes are positive, this section of the rule also includes a new definition of “sex” to be limited to only male or female, dismissing broader medical and scientific understandings of gender identity. This change raises serious concerns about how nondiscrimination protections may be interpreted or enforced.

What Advocates Can Do

These impacts are not inevitable. This rule is not yet finalized, and partners and advocates have the opportunity to submit comments on the proposed changes. Families USA strongly encourage advocates and all interested parties to submit comment letters using this blog and other resources as a template and share how these changes may impact consumers and families for your community and your state.

Comments are due by March 13.